Center for Care Coordination-Team Lead Utilization Review Nurse- Full Time

Connecticut Children's • $80K — $95K *
Hartford, CT 06106In-Person
Healthcare
Less than 5 years of experience
Today
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Job Overview by Ladders

Qualifications

  • Bachelor of Science in Nursing (BSN) required
  • 3 years' nursing experience in a healthcare setting required
  • Pediatric nursing experience preferred
  • Prior experience in Utilization Review preferred
  • Prior experience in Case Management or Discharge Planning preferred
  • Connecticut Nursing License required
  • Case Management Certification preferred

Responsibilities

  • Provide clinical support and supervision to UR nurses
  • Schedule UR nurse coverage
  • Review and maintain UR policies and procedures
  • Onboard and support new staff members
  • Track metrics and improve processes in collaboration with management
  • Conduct chart reviews for compliance and appropriateness of care
  • Communicate reimbursement information to the healthcare team

Benefits

  • Comprehensive onboarding program
  • Continuous professional development opportunities
  • Engagement activities to support team cohesion
  • Opportunity to influence patient care processes
  • Access to institutional resources for ongoing education
Full Job Description
Job Description

The Team Lead for Utilization Review (UR) is responsible for the day-to-day activities and oversight of the UR Nurses, under the guidance and support of the Manager of Case Management and Director of the Center. Provides leadership and direction around scheduling, supervision and daily operations, while looking strategically at how workflow and process improvement can optimize and improve the role of Case Management and patient/family care through the institution. Lead will identify challenges and systems issues that need to be elevated to the Manager and Center Leadership.

Responsibilities

Team Lead-20%:
  • Daily clinical support and supervision of UR nurses.
  • Scheduling for UR coverage.
  • UR Policies and Procedure review and maintenance.
  • Onboarding and support of new staff.
  • Individual and team supervision / support following challenging cases.
  • Work with Manager to establish and track metrics, data and initiatives that improve process
  • UR Team Communications.
  • Assists Manager in completing performance evaluations.
  • Provides formal and informal support of members through engagement activities, team supervision and staff meetings.
  • Develop and maintain effective and efficient processes for determining the defensible hospitalization status based on regulatory and reimbursement requirements of various commercial and government payers. -20%
  • Performs chart review of assigned patients to identify quality, timeliness, and appropriateness of patient care. Conducts hospitalization reviews for Medicaid beneficiaries, as well as other insurers and self-pay patients, based on appropriate guidelines. Uses these criteria to screen for appropriateness of level of care based on medical record documentation. -9%
  • Gathers clinical information to conduct continued stay utilization review activities with payers pursuant to department policies and procedures and the Utilization Review Plan. -5%
  • Escalates cases as appropriate for secondary review. -5%
  • Performs concurrent and retrospective clinical reviews utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies, and timelines. -5%
  • 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. -9%
  • Identifies and consistently documents information on any progression of care or patient flow barriers using the designated electronic tool used to track avoidable days/delays. -2.5%
  • Engages hospital case management and care team colleagues in collaborative problem solving regarding appropriate utilization of resources. -5%
  • Represents Utilization Management at various committees, as needed. -.5%
  • Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes. 2


  • Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. -10%
  • Provides consultation and education to physicians and other qualified practitioners regarding medical record documentation necessary to support the ordered level of care. -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. -1.0%
  • Verifies in-network verses out-of-network benefits and communicates data to the patient and healthcare team as indicated. -.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.
  • 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. -5%
  • Performs other job-related duties as assigned 0


Qualifications

Education and/or Experience Required:
  • Education: Bachelor of Science in Nursing (BSN)
  • Experience: 3 years' nursing 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 of 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.
  • UR Team Lead has strong clinical skills and a well-developed knowledge of utilization management, with a focus on medical necessity determinations. Lead maintains current and accurate knowledge regarding commercial and government payers including regulatory requirements.

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.
  • Strong working knowledge of medical necessity tools such as InterQual® and Milliman Care Guidelines® and be proficient in medical record reviews.
  • UR Lead will support process improvement activities and report key metrics to facility leadership as requested.
  • The UR Lead will demonstrate an ability to effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment.
  • Lead will provide support to the hospital's UM Committee as needed and collaborate with multiple leaders at various levels throughout the organization.

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.

About Connecticut Children's

Connecticut Children's Careers

There has never been a better time to explore the job opportunities at Connecticut Children's, a leading pediatric healthcare system. As a beacon of innovation and leadership in child health, Connecticut Children's offers a range of career paths for professionals passionate about making a difference in the lives of children.

Work You’ll Do

Join Connecticut Children's dynamic team to contribute to a mission-driven environment where the health and well-being of children come first. The company stands at the forefront of pediatric healthcare, combining clinical expertise with compassionate care. Professionals at Connecticut Children's lead the way in pediatric medicine, not only by providing exceptional care but also by advancing the field through research and innovation. The team's dedication to growth and learning ensures that every member has the opportunity to expand their skills and advance their career.

Explore Job Opportunities and Internships

Connecticut Children's offers a variety of positions and internships that cater to a wide range of professional skills and interests. From clinical roles to administrative positions, the company is always looking for dedicated individuals to join their team.

Innovative Work Environment

Connecticut Children's fosters an environment of innovation where team members from diverse backgrounds bring their unique perspectives to solve challenges. This collaborative atmosphere is pivotal for developing solutions that enhance patient care and operational efficiency.

Commitment to Diversity and Professional Development

The commitment to diversity and professional development at Connecticut Children's is evident through comprehensive diversity training programs and leadership development opportunities. These initiatives ensure that all team members are equipped to lead, innovate, and grow within the company.

Benefits and Culture

Employees at Connecticut Children's enjoy a supportive culture that values work-life balance, along with a competitive benefits package that supports both personal and professional growth. The company's culture is built on a foundation of respect, integrity, and a shared commitment to improving the lives of children.

Join the Team

Connecticut Children's is actively hiring and encourages interested candidates to apply. Prospective team members are invited to explore open positions that match their skills and interests. The hiring process at Connecticut Children's is designed to be transparent and engaging, starting from the initial application to the interview and eventual onboarding.

Stay Connected

Stay informed about new job opportunities, company updates, and industry insights by joining Connecticut Children's professional network. Engaging with Connecticut Children's through various networking events can provide valuable connections and insights into the company's operations and culture.

Career Advancement

With a strong emphasis on career advancement, Connecticut Children's supports its employees through ongoing training, mentorship, and access to cutting-edge resources. Whether you are just starting your career or looking to take it to the next level, Connecticut Children's provides the tools needed to succeed in a competitive healthcare environment.

Apply Today

Ready to make a significant impact in pediatric healthcare? Review the list of available positions, tailor your resume, and prepare for a rewarding journey at Connecticut Children's. Discover how your expertise can contribute to a healthier future for children.

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Keep Up to Date

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