Utilization Management RN — Care Optimization (Hybrid)

Trinity Health; Hartford (CT); Hybrid; USD 85,000 - 110,000; Full time

Job summary

Saint Francis Hospital in Connecticut is seeking an Utilization Management (UM) Registered Nurse to review services and treatment plans, ensuring high quality, cost-effective patient care. Using InterQual and Milliman guidelines, you’ll collaborate with providers and care teams to support optimal health outcomes.

The role requires an accredited nursing graduate with CT RN license; BSN preferred; 3+ years in utilization management or case management in acute care.

Qualifications

• Graduate of an accredited School of Nursing.
• Current, unrestricted Connecticut RN license.
• BSN preferred; RN with BSN encouraged to apply.
• 3+ years of Utilization Management, Utilization Review, Case Management, or related experience in an acute care hospital.
• Experience using InterQual and/or Milliman clinical criteria.

Responsibilities

• Conduct concurrent utilization reviews to determine appropriate level of care using established criteria.
• Initiate, manage, and track admission authorizations and payer communications.
• Review and monitor insurance denials and support appeals processes.
• Collaborate with physicians, case managers, and interdisciplinary care teams to optimize care plans and discharge planning.
• Ensure documentation reflects severity of illness, medical necessity, and resource utilization.
• Partner with Finance, HIM, Admitting, and other departments to support utilization management activities.
• Work with care coordination teams to promote high-quality, cost-effective outcomes.
• Maintain compliance with regulatory, accreditation, and payer requirements.

Skills

Utilization Management

Case Management

InterQual/Milliman criteria

Interdisciplinary collaboration

Education

BSN preferred

Bachelor of Science in Nursing

Tools

EMR systems

Job description

Saint Francis Hospital in Connecticut is seeking an Utilization Management (UM) Registered Nurse to review services and treatment plans, ensuring high quality, cost-effective patient care. Using InterQual and Milliman guidelines, you’ll collaborate with providers and care teams to support optimal health outcomes.

The role requires an accredited nursing graduate with CT RN license; BSN preferred; 3+ years in utilization management or case management in acute care.