Portal of Entry (ED) Utilization Management Nurse- 32hr- Onsite

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.Portal of Entry (ED) Utilization Management Nurse: 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.Education and/or Experience Required:* Education: Bachelor of Science in Nursing (BSN)* Experience: 3 years of nursing experience in a healthcare settingEducation and/or Experience Preferred:Experience:Pediatric nursing experiencePrevious experience in Utilization ReviewPrevious experience in Case Management or Discharge planningLicense 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 standardsProvides 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 resourcesFunction 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%