Center Care Coordination-Team Lead Utilization Review Nurse

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

Hartford, CT, United States (Hybrid)

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.

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.

• 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…