Utilization Review Nurse (40 Hour) (Office/On-site)

State of Connecticut; Hartford (CT); On-site; USD 90,000 - 110,000; Full time

Benefits offered by this job

Professional growth opportunities

Healthy work-life balance

Job summary

The State of Connecticut's Department of Mental Health and Addiction Services (DMHAS) seeks a Utilization Review Nurse in Hartford to join the Capitol Region Mental Health Center. This inpatient unit role is full-time, with standard daytime hours, and focuses on review of care, insurance verification, and cost containment.

Ideal candidates hold an RN license, with 3 years of nursing experience and 1 year in relevant settings; a BSN may substitute.

Qualifications

• Three (3) years as a Registered Nurse.
• One (1) year in hospital or institutional nursing or medical review.
• Bachelor's degree may substitute for one year of experience.
• Experience with reimbursement of healthcare services is preferred.
• Knowledge of insurance verification tools is preferred.
• Familiarity with State/Federal utilization review standards.

Responsibilities

• Assess, audit, and evaluate medical records for quality and level of care.
• Apply federal/state statutes and regulations in daily work.
• Assist with authorization of services for Medicare/Medicaid and private insurers.
• Perform insurance verification using listed tools.
• Update insurance information in the WITS system.
• Summarize audit findings and report corrections to relevant teams.
• Participate in treatment team meetings to align plans of care.
• Maintain knowledge of billing and coding for services provided.
• Monitor the Utilization Management Plan and chair committee meetings.

Skills

Nursing knowledge

Regulatory knowledge

Interpersonal skills

Oral and written communication

Analytical skills

Education

RN license (CT or Multistate/Compact)

Tools

Inovalon

CTDSS

AP

NGS Connex

WITS system

Job description

Introduction

Are you a Registered Nurse (RN) with experience in hospital or institutional nursing, in a medical treatment facility, in rehabilitative or occupational nursing or providing medical review of insurance claims?

The Position

The State of Connecticut, Department of Mental Health and Addiction Services (DMHAS) is now hiring for a Utilization Review Nurse to join our team!

Highlights

• FACILITY: Capitol Region Mental Health Center (CRMHC)
• LOCATION: Hartford, CT
• UNIT: Inpatient
• SCHEDULE: Full-Time (40 hours/week), Monday - Friday, 8:00 AM - 4:30 PM (First Shift)
• POSITION NUMBER: 26806

What We Can Offer You

Visit our new State Employee Benefits Overview page!

• Professional growth and development opportunities
• A healthy work/life balance to all employees

NEW! We're excited that Connecticut has joined the Nurse Licensure Compact effective October 1, 2025. Visit the Nurse Licensure Compact for more details.

Discover the Opportunity To:

• Assess, evaluate, and audit medical records to ensure quality of care and confirm clients meet the appropriate level of care
• Apply knowledge of federal and/or state statutes, regulations, and guidelines in daily work
• Assist with authorization of services for Medicare, Medicaid, and private insurance companies
• Perform insurance verification using tools such as Inovalon, CTDSS, AP, and NGS Connex
• Update insurance information using the WITS system
• Summarize and analyze audit findings and report needed corrections to the appropriate disciplines
• Participate in treatment team meetings to ensure each client’s plan of care reflects their identified needs
• Apply knowledge related to billing and coding for services provided
• Monitor and update the Utilization Management Plan and chair the Utilization Management Committee

About Us

DMHAS is a health care agency whose mission is to promote the overall health and wellness of persons with behavioral health needs through an integrated network of holistic, comprehensive, effective, and efficient services and supports that foster dignity, respect, and self-sufficiency in those we serve.

CRMHC is a community-based mental health center serving Hartford, West Hartford, Farmington, Avon, Canton, and Simsbury. CRMHC partners closely with DMHAS-funded programs across the Greater Hartford region, working with 15 nonprofit agencies to provide a comprehensive network of behavioral health services for adults with serious psychiatric conditions and co-occurring substance use disorders.

Please Note

A comprehensive medical examination, including a drug screening, will be required of all applicants upon a conditional offer of employment.

All state employees must adhere to Connecticut's Policy for a Drug Free Workplace.

Purpose of Job Class (Nature of Work)

In a state agency this class is accountable for a full range of duties involving the assessment and review of health care delivery systems or medical cost containment activities and programs related to agency efforts to promote cost effective quality of care of cost containment in accordance with various federal and/or state statutes, regulations and guidelines.

Examples of Duties

• Performs a variety of duties related to review of various types of health and medical care delivery and reimbursement systems;
• Participates in utilization review and/or quality assurance programs;
• Conducts various types of case reviews for quality and appropriate medical management, cost containment, peer review and rehabilitation;
• Summarizes and analyzes data;
• Prepares statistical reports;
• Implements decisions in program according to revisions in standards;
• Attends professional workshops, seminars and in-service training;
• Maintains up to date knowledge of all changes in relevant discipline;
• Monitors personal injuries and medical costs to evaluate need for services billed for appropriate injuries;
• May monitor agency and third-party administrator files to oversee contractor handling;
• May review medical records of various health care eligibility, resource unit referral and/or compliance with federal funding provisions;
• Performs related duties are required.

Knowledge, Skill and Ability

• Considerable knowledge of principles, practices and current trends in nursing;
• Knowledge of and ability to apply relevant state and federal laws, statutes and regulations;
• standards of practice of medicine and nursing as well as other health care disciplines;
• regulations and standards pertaining to utilization review;
• care and service delivery to injured workers;
• Skills interpersonal skills;
• oral and written communication skills;
• Ability to analyze patient profile and progress charts to evaluate proper care and treatment.

Minimum Qualifications - General Experience

Three (3) years of experience as a Registered Nurse.

Minimum Qualifications - Special Experience

One (1) year of the General Experience must have been in hospital or institutional nursing, in a medical treatment facility, in rehabilitative or occupational nursing or providing medical review of insurance claims.

Minimum Qualifications - Substitutions Allowed

A Bachelor's degree in nursing may be substituted for one (1) year of the General Experience.

Preferred Qualifications

• Experience with reimbursement of healthcare services
• Experience and knowledge of insurance verification tools
• Experience with State and Federal regulations and standards related to utilization review

Special Requirements

Incumbents in this class must possess and retain a license as a Registered Nurse in Connecticut OR hold a Multistate or Compact Registered Nurse license.

Incumbents in this class may be required to travel.

Conclusion

AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER

The State of Connecticut is an equal opportunity/affirmative action employer and strongly encourages the applications of women, minorities, and persons with disabilities.

Acknowledgement

As defined by Sec. 5-196 of the Connecticut General Statutes, a job class is a position or group of positions that share general characteristics and are categorized under a single title for administrative purposes. As such, a job class is not meant to be all-inclusive of every task and/or responsibility.