What are the responsibilities and job description for the Utilization Review Nurse Part Time Remote position at Connecticut Children's?
Job Description
The utilization review nurse is part of a team that will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation as well as appropriate clinical documentation through extensive interaction with physicians, nursing staff, case managers, other patient caregivers and Health Information Management coding staff to ensure clinical documentation reflects the clinical treatment, decisions, diagnosis and the level of service rendered. The UR nurse serves as a resource to all members of the health care team on appropriate status, documentation guidelines, provide guidance and support, as well as assisting with education and training related to improving clinical documentation on an ongoing basis.
Responsibilities
Utilization Review :
- Perform admission, concurrent and retrospective medical reviews to provide to the payers for reimbursement.
- Functions as the liaison between various hospital departments, medical staff and payers on issues related to medical necessity for admission and continued stay.
- The UR / CDI nurse maintains open, transparent and clear lines of communication with the physician advisors.
- Provides UM education to clinical staff as needed.
- Applies standardized criteria and guidelines to assist in the determination of appropriateness of admissions and assignment of patient class (i.e. observation, inpatient and outpatient).
- Assist in monitoring wasted resources while maintaining uncompromisingly high quality of care. Responsible for maintaining and ensuring the admission process remains fully compliant with Medicare and Medicaid regulations.
- Acts as a resource to Care Management department regarding utilization, insurance and payer issues.
- Identifies potential problems regarding payment eligibility for clinical services and recommends corrective action.
- Participates in UR meetings.
Qualifications
Education and / or Experience Required :
Education and / or Experience Preferred :
License and / or Certification
Knowledge, Skills, and Abilities
Knowledge of :
Skilled at :
Ability to :
About Us
Connecticut Children's is the only health system in Connecticut that is 100% dedicated to children. Established on a legacy that spans more than 100 years, Connecticut Children's offers personalized medical care in more than 30 pediatric specialties across Connecticut and in two other states. Our transformational growth establishes us as a destination for specialized medicine and enables us to reach more children in locations that are closer to home. Our breakthrough research, superior education and training, innovative community partnerships, and commitment to diversity, equity and inclusion provide a welcoming and inspiring environment for our patients, families and team members.
At Connecticut Children's, treating children isn't just our job - it's our passion. As a leading children's health system experiencing steady growth, we're excited to expand our team with exceptional team members who share our vision of transforming children's health and well-being as one team.
