Utilization Review Nurse Coordinator (40 Hour)(Office/On-site)

Description

• Conduct various types of case reviews for quality and appropriate medical management, cost containment, peer review and rehabilitation;
• May lead an inspection team in IPR/UR and licensing review functions;
• Maintains records and documentation;
• May review medical records and compile documents for case presentations;
• Act as liaison with other operating units, agencies and outside officials regarding program policies and procedures;
• Participate in utilization review and/or quality assurance programs;
• Audits process according to utilization guidelines and ensures process is completed within appropriate regulatory time frames;
• Identifies errors in coding of MDS and RAI forms during completion process;
• Prepares comprehensive, complex investigative reports;
• Communicates to leadership and interdisciplinary team members any changes to directives and guidelines;
• Reviews medical care that was provided to individuals;
• Schedules, assigns, oversees and reviews work;
• Acts as resource to all areas involved in Minimum Data Set (MDS) process;
• care and service delivery to injured workers.
• May notify acute care hospitals of scheduled utilization review including conducting second level review of cases and case referral to a physician consultant for final disposition;
• Participates in the reviews of events, overall care, quality of life and medical care preceding a death;
• Coordinates workflow and determines priorities to assure highest quality of care with efficient utilization of available services;
• Routinely conducts chart audits and maintains log of deficiencies and discrepancies;
• Develops plan of action to correct identified quality deficiencies;
• May coordinate review and audit of occupational injury and/or disease disability cases for purpose of determining medical management, cost containment, peer review and rehabilitation;
• May supervise Utilization Review Nurses and other staff engaged in review of medical records of individuals in state health care facilities for purposes of maximizing reimbursement revenue via Medicare Part B programs;
• Ensures outcome of process is accurate document for care planning;
• Trains all Health Care Team members on Resident Assessment Instrument (RAI) care planning system;
• Provides staff training and assistance;
• Attend professional workshops, seminars and in-service training;
• May supervise Utilization Review Nurses and other staff;
• Asses, evaluates and monitors documentation of all hospital disciplines when performing case reviews;
• Acts as liaison with other operating units, agencies and outside officials regarding program policies and procedures;
• Prepares reports and correspondence;
• Interviews alleged victims, direct care providers, families and other potential witnesses;
• Ensures compliance with state statutes, federal Veterans Affairs regulations and state Department of Veterans Affairs policies and procedures;
• Prepare reports and correspondence;
• May review medical records of various health care eligibility, resource unit referral and/or compliance with federal funding provisions;
• Attends professional workshops, seminars and in-service training;
• May testify in court proceeding;
• Works cooperatively with State and local police, State's Attorneys and other protective services organizations;
• Conducts complex investigations into allegations of abuse or neglect of individuals with an intellectual disability;
• May provide pre-certification for and coordination of inmates admitted to and discharged from acute care facilities;
• May provide information and assistance to the Independent Mortality Review Board or Fatality Review Board for Persons with Disabilities;
• Establishes and maintains program protocols and procedures;
• Assesses, evaluates and monitors documentation of all hospital disciplines when performing case reviews;
• May supervise and participate in hospital Medicare and Medicaid reimbursement programs;
• May testify in court;
• Assists in the investigation to determine if the death is a result of abuse or neglect;
• Coordinates activities of care team, plans and schedules meetings, tracks input and attendance;
• Reviews medical records for pertinent information related to investigations;
• Conduct or assist in conducting performance evaluations;
• May supervise and participate in hospital Medicare and Medicaid reimbursement programs including preparation of appeals on behalf of a facility relative to intermediate denials;
• May monitor agency and third-party administrator files to oversee contractor handling;
• Providing nursing oversight regarding the Omnibus Budget Reconciliation Act (OBRA).
• Coordinate workflow and determine priorities to assure highest quality of care with efficient utilization of available services;
• Assures ongoing record documentation supports MDS and RAI coding;
• Enters MDS data into information system;
• Monitors and manages timely electronic transmission of MDS program data;
• Conducts complex investigations into cases where a death has resulted of an individual with an intellectual disability for whom the Department of Developmental Services has direct or oversight responsibility for medical care;
• Implement decisions in program according to revisions in standards;
• Conducts or assists in conducting performance evaluations;
• Stay connected! Log in daily to your JobAps Personal Status Board to track your status and check email (including spam/junk folders) for updates and tasks.
• May conduct entrance and exit interviews of care providers;

Requirements

• Educational Credits: List your earned credits and degrees from accredited institutions accurately on your application. To receive educational credits towards qualification, the institution must be accredited. If the institution of higher learning is located outside of the U.S., you are responsible for providing documentation from a recognized USA accrediting service which specializes in determining foreign education equivalencies to the contact listed below.
• interpersonal skills;
• Experience using Microsoft applications, including Outlook, Excel, Teams, and Word.
• Knowledge of Minimum Data Set process in a long-term care setting and coordination of an interdisciplinary team;
• Incumbents in this class may be required to travel.
• Referral Questions: This posting may require completion of additional Referral Questions (RQs), which must be completed by the questionnaire’s expiration date. If requested, RQs can be accessed via an email sent to you after the job close date or by visiting your JobAps Personal Status Board (Certification Questionnaires section).
• Incumbents in this class must possess and retain a current license as a Registered Nurse in Connecticut OR hold a Multistate or Compact Registered Nurse license.
• Supervisory ability.
• Experience coordinating with Private Agency Providers, Skilled nursing Facilities.
• Experience with discharge planning from hospitals or Skilled Nursing facilities, to family or own homes.
• Knowledge of investigatory methods and techniques;
• skills in the preparation of extensive written reports;
• Experience with current Department of Developmental Services Nursing Policies, Procedures, and Regulations and mortality review process.
• Considerable ability to analyze individual profiles and progress charts;
• interviewing skills;
• Experience working with individuals with intellectual and developmental disabilities, assessing their medical and behavioral needs across the life span.
• Ability to research and analyze data.
• Experience in a supervisory role.
• Considerable knowledge of
• Work schedule flexibility is required to meet the needs of the agency.
• oral and written communication skills;
• Will be required to travel.
• Experience auditing charts for quality assurance compliance.
• and ability to apply relevant state and federal laws, statutes and regulations;
• Ability to utilize computer software.

Benefits

• standards of medical care
• A healthy work-life balance to all employees!
• Hybrid schedule may be requested upon successful completion of a Working Test Period.
• Regular Days Off: Saturday, Sunday
• Professional growth and paid professional development opportunities.
• The State of Connecticut is an eligible Public Service Loan Forgiveness employer, meaning you may be eligible to have qualifying student loans forgiven after 10 years of service. Click here for more information.
• various types of residential placement facilities;

Training + Development

Interview process

Visa Sponsorship

Security clearance