Utilization Review Specialist, DH
Utilization Review Specialist, DH
Posted on :
17-06-2025
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1 Vacancy
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Job Description
Description
Position at Danbury Hospital
Nuvance Health has a network of convenient hospital and outpatient locations Danbury Hospital New Milford Hospital Norwalk Hospital and Sharon Hospital in Connecticut and Northern Dutchess Hospital Putnam Hospital Center and Vassar Brothers Medical Center in New York plus multiple primary and specialty care physician practices locations including The Heart Center a leading provider of cardiology care and two urgent care offices. Non-acute care is offered through various affiliates and the Home Care organizations.
Work Type : Full Time
Hours : 36
Shift: 9am-930pm; including every 3rd weekend rotation
Summary:
The purpose of the Utilization Management Nurse is to support the physician the interdisciplinary team and organization with the underlying objective of enhancing the quality of clinical outcomes while managing the cost of care and providing timely and accurate clinical information to payors. Utilization management provides clinically based first level medical necessity reviews by using standardized published criteria to certify medical necessity for admission and continued stay of all patients receiving care in the hospital. Progression of care is managed by using bench marked evidence-based criteria (i.e. InterQual/MCG).
Responsibilities:
1)Ensures that Admission Review using InterQual or MCG is completed within 24 hours of admission.
2) Identifies incomplete reviews from work queues.
3) Validates admission order on new admits/observations daily
4)Ensures order in chart coincides with the MCG and/or InterQual review or CMS 2 Midnight Rule for status and level of care
5) Resolves any discrepancy at the time of review. If unable to resolve escalate to PA and CM Leadership
6) Delivers the MOON notice to those patients who have been downgraded to Observation status.
7) If concurrent case has been determined inpatient by the attending and case does not meet criteria per first level medical necessity review discuss case with the attending MD to gather additional clinical information and request additional documentation to support inpatient level of care. If inpatient level of care is still not met send to PA for second level review
8) Identifies reviews that need to be completed and sent to specific payers
9) Prioritizes review of all OBS and Outpatients
10) Concurrent reviews regardless of payor will be completed every 3-4 days or more frequently if criteria are waning. Sends concurrent reviews to payor upon request.
11)Ensures all days are authorized/certified by respective payers and communicate any issues/denials to department leadership.
12) Forwards reviews that require secondary physician review to appropriate resource (Physician Advisor)
13) Coordinates with care team in changing LOC/Status if needed
14) Notifies care team when patient is not meeting medical necessity per InterQual or MCG review and escalate as needed.
15) Denotes relevant clinical information to proactively communicate to payers for authorizations for treatments procedures and Length of Stay send clinical information as required by payer.
16) Completes and distributes appropriate HINNs.
17) Notifies appropriate parties of any changes in financial class including conversions HINNs and Condition Code 44s
18) Maintains and Models Nuvance Health Values.
19) Demonstrates regular reliable and predictable attendance.
20) Performs other duties as required.
Hours : 36
Shift: 9am-930pm; including every 3rd weekend rotation
Summary:
The purpose of the Utilization Management Nurse is to support the physician the interdisciplinary team and organization with the underlying objective of enhancing the quality of clinical outcomes while managing the cost of care and providing timely and accurate clinical information to payors. Utilization management provides clinically based first level medical necessity reviews by using standardized published criteria to certify medical necessity for admission and continued stay of all patients receiving care in the hospital. Progression of care is managed by using bench marked evidence-based criteria (i.e. InterQual/MCG).
Responsibilities:
1)Ensures that Admission Review using InterQual or MCG is completed within 24 hours of admission.
2) Identifies incomplete reviews from work queues.
3) Validates admission order on new admits/observations daily
4)Ensures order in chart coincides with the MCG and/or InterQual review or CMS 2 Midnight Rule for status and level of care
5) Resolves any discrepancy at the time of review. If unable to resolve escalate to PA and CM Leadership
6) Delivers the MOON notice to those patients who have been downgraded to Observation status.
7) If concurrent case has been determined inpatient by the attending and case does not meet criteria per first level medical necessity review discuss case with the attending MD to gather additional clinical information and request additional documentation to support inpatient level of care. If inpatient level of care is still not met send to PA for second level review
8) Identifies reviews that need to be completed and sent to specific payers
9) Prioritizes review of all OBS and Outpatients
10) Concurrent reviews regardless of payor will be completed every 3-4 days or more frequently if criteria are waning. Sends concurrent reviews to payor upon request.
11)Ensures all days are authorized/certified by respective payers and communicate any issues/denials to department leadership.
12) Forwards reviews that require secondary physician review to appropriate resource (Physician Advisor)
13) Coordinates with care team in changing LOC/Status if needed
14) Notifies care team when patient is not meeting medical necessity per InterQual or MCG review and escalate as needed.
15) Denotes relevant clinical information to proactively communicate to payers for authorizations for treatments procedures and Length of Stay send clinical information as required by payer.
16) Completes and distributes appropriate HINNs.
17) Notifies appropriate parties of any changes in financial class including conversions HINNs and Condition Code 44s
18) Maintains and Models Nuvance Health Values.
19) Demonstrates regular reliable and predictable attendance.
20) Performs other duties as required.
Education: ASSOCIATES LVL DGRE
Preferred : Two Years of Utilization Review experience
Required : CT Registered Nurse License
Preferred : Two Years of Utilization Review experience
Required : CT Registered Nurse License
Working Conditions:
Manual: significant manual skills/motor coord & finger dexterity
Occupational: Little or no potential for occupational risk
Physical Effort: Sedentary/light effort. May exert up to 10 lbs. force
Physical Environment: Generally pleasant working conditions
Company: Danbury Hospital
Org Unit: 152
Department: Care Coordination-DH
Exempt: Yes
Salary Range: $45.29 - $84.11 Hourly
EOE including disability/vets.
We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business. If you believe you require such assistance to complete this form or to participate in an interview please contact Human Resources at (for reasonable accommodation requests only). Please provide all information requested to assure that you are considered for current or future opportunities.
Required Experience:
Unclear Seniority
Employment Type
Full Time
Key Skills
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