Utilization Management Nurse Jobs in Springfield, MA

Applicants must be residents of Connecticut, Massachusetts, or New York to be considered for this position.

The Center

Connecticut Children's Center for Care Coordination (The Center) is dedicated to the integration of care coordination through the delivery of innovative programs, providing technical assistance, disseminating best practices, and building inclusive partnerships to strengthen families and build stronger communities. The Center utilizes a universal, evidence based, research informed, and policy driven approach to enhanced care coordination that not only meets the interrelated medical, developmental, behavioral, and social needs of children, but enhances the care giving capacity of families. This team reports to The Center for their leadership.

Position Details

The Portal of Entry Utilization Management Nurse (POE) has strong clinical skills and a well-developed knowledge of utilization management, with a focus on medical necessity determinations. The candidate should possess a working knowledge of medical necessity tools such as InterQual and Milliman Care Guidelines and be proficient in medical record reviews. This individual supports the Care Management program by developing and/or maintaining effective and efficient processes for determining the defensible hospitalization status based on regulatory and reimbursement requirements of various commercial and government payers. The purpose of the POE is to support the physician and other qualified practitioners in determination of defensible patient class at the time of admission in the ED. The POE serves as a resource to all members of the health care team on defensible patient status and promotes effective utilization of hospital resources.  

This individual maintains current and accurate knowledge regarding commercial and government payers including regulatory requirements. The POE nurse will function in accordance with facility policies and processes. This individual will support process improvement activities and report key metrics to facility leadership as requested. audiences. The POE Nurse effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment. The POE Nurse participates and provides support to the hospital's Utilization Management Committee. They collaborate with multiple leaders at various levels throughout the organization. This is an on-site role interfacing with the admitting physician on cases to support industry-accepted level of care criteria.

Education and/or Experience Required:

• Education: Bachelor of Science in Nursing (BSN)
• Experience: 3 years of nursing experience in a healthcare setting

Education and/or Experience Preferred:

• Experience:
  • Pediatric nursing experience
  • Previous experience in Utilization Review
  • Previous experience in Case Management or Discharge planning

License and/or Certification Required:

• State if Connecticut Nursing License.

License and/or Certification Preferred:

• Case Management Certification.

Knowledge, Skills and Abilities:

Knowledge:

• Demonstrate working knowledge of how to interpret and apply medical care criteria.
• Knowledge of community resources, treatment options, home health availability, funding options and special programs.

Skills:

• Coordinates management of care for a specified patient population; follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with hospital standards
• Provides ongoing support and expertise through comprehensive assessment, care planning, plan implementation and overall evaluation of individual patient needs.
• Skilled in the operation of the computer including proficiency in Microsoft Office Word, ability to use/update Excel spreadsheets and ability to navigate EPIC. 

Abilities:

• Self-directed/motivated, organized, diplomatic and team-oriented.
• Function in a high energy, fast moving environment.
• Maintain flexibility as determined by acuity of medical unit.
• Prioritize case load.
• Collaborate with various disciplines. 
• Communicate effectively and efficiently.
• Prioritize and manage multiple tasks.
• Excellent written and verbal communication skills.

• Performs chart review of assigned patients to identify quality, timeliness, and appropriateness of patient care. Conducts hospitalization reviews based on appropriate guidelines. Uses these criteria to screen for defensible level of care based on medical record documentation. Escalates cases as appropriate for secondary review. -15%
• Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals for secondary review. Identifies, develops, and implements strategies to reduce length of stay and resource consumption in conjunction with discharge planning staff. -15%
• Provides consultation and education to physicians and other qualified practitioners regarding medical record documentation necessary to support the ordered level of care. -10%
• Performs and documents initial / admission medical necessity review for all points of entry. -10%
• Communicates initial medical necessity review results with emergency department and admitting providers as necessary to support defensible admission status orders. -10%
• Proactively collaborates with emergency department providers and staff to identify patients likely to require hospitalization. -10%
• Works in conjunction with emergency department social workers and other staff to identify and secure available and necessary services to support clinically appropriate hospital admission avoidance. -3.0%
• Obtains information from patient, caregivers, providers of services, insurance company, benefits administrators and others as necessary. - .5%
• Conveys benefit data and options, programs and other forms of assistance that may be available to the patient, and negotiates for services as indicated. -.5%
• Communicates pertinent reimbursement information to healthcare team while observing patient right to confidentiality. -.5%
• Verifies in-network verses out-of-network benefits and communicates data to the patient and healthcare team as indicated.  -.5%
• Pre-Admission Reviews -15%
  • Performs prospective medical record review of patients scheduled for outpatient/inpatient procedures scheduled in the hospital setting. 
  • Works in collaboration with Finance to identify the appropriate setting for scheduled admissions, procedures, and medication administration by reviewing pertinent clinical information and collaborating to obtain prior authorization when necessary.
  • Screens scheduled patients to ensure that they are scheduled in a defensible utilizing industry-accepted level of care criteria. 
  •  Is able to review and interpret the patient's medical record to supply appropriate information to third-party payers as necessary. 
     

Additional Responsibilities -5%

• Collaborates with other members of The Center team to coordinate the right care, in the right setting, at the right time for CT Children's patients.
• Assist with discharge planning as necessary to coordinate the right care, in the right setting and the right time for CT Children's patients.
• Identify gaps in care/resources and address issues that negatively impact access to care, services, and resources
• Function as a change agent, advocate, and resource person for family and healthcare team to identify and resolve performance improvement issues within the system. 
• Commitment to ONE TEAM Culture. -2.5%
• Performs other job-related duties as assigned. -2.5%