Utilization Review Nurse

🔥 9 hours ago

🦌 Connecticut – Remote

🦌 Connecticut – Remote

💵 $42 - $63 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 2%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Connecticut Children's

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1996

⚕️ Healthcare Insurance

🏥 Healthcare

📚 Education

Healthcare Insurance • Healthcare • Education

Connecticut Children's is a leading pediatric healthcare provider dedicated to transforming children's health and well-being. With over 40 locations across Connecticut, Western Massachusetts, and Eastern New York, it offers a comprehensive range of specialty care services, including prenatal care, pediatric surgery, and mental health support tailored specifically for children and adolescents. The organization is committed to addressing both the physical and emotional needs of children, while also engaging in research and community initiatives to promote overall health and wellness.

📋 Description

• Perform chart reviews to assess quality, timeliness, appropriateness, and level of care • Conduct hospitalization reviews for Medicaid, other insurers, and self-pay patients using applicable guidelines • Gather clinical information for continued-stay utilization reviews with payers • Escalate cases for secondary review when appropriate • Perform concurrent and retrospective clinical reviews in compliance with regulations, policies, and timelines • Adhere to CMS utilization-review guidelines • Develop and implement strategies to reduce length of stay and resource consumption with discharge-planning staff • Identify and document progression-of-care barriers, avoidable days, and delays • Collaborate with hospital case management and care teams on resource utilization • Represent Utilization Management at committees as needed • Maintain utilization-software documentation for each patient • Educate physicians and qualified practitioners on documentation supporting the ordered level of care • Communicate reimbursement information and verify in-network and out-of-network benefits • Keep current on regulatory changes and national and local coverage determinations • Promote evidence-based protocols and order sets • Apply level-of-care criteria and clinical critical thinking to advocate for appropriate resource utilization • Collaborate with The Center team to coordinate appropriate care settings and timing • Identify care and resource gaps and address access issues • Support performance-improvement initiatives as a change agent, advocate, and resource person • Provide support to the hospital’s Utilization Management Committee and report key metrics to leadership as requested

🎯 Requirements

• Bachelor of Science in Nursing (BSN) • 3 years’ nursing experience in a healthcare setting • Current State of Connecticut Registered Nurse licensure or nurse licensure compact (NLC), maintained thereafter • Working knowledge of interpreting and applying medical care criteria • Knowledge of community resources, treatment options, home health availability, funding options, and special programs • Proficiency in Microsoft Office Word • Ability to use and update Excel spreadsheets • Ability to navigate EPIC • Ability to function in a high-energy, fast-moving environment • Ability to maintain flexibility based on medical-unit acuity • Ability to prioritize caseload and manage multiple tasks • Ability to collaborate with various disciplines • Excellent written and verbal communication skills • Pediatric nursing experience preferred • Previous Utilization Review experience preferred • Previous Case Management or Discharge Planning experience preferred • Case Management Certification preferred

🏖️ Benefits

• Medical insurance • Dental insurance • Vision insurance • Hospital-paid life insurance • Hospital-paid disability coverage • Paid time off • Leave programs • Education and training assistance • Retirement savings plan with hospital match • Employment assistance program

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume