Utilization Management Specialist

William Backus Hospital Wethersfield , CT 06109

Posted 5 months ago

Work where every moment matters.

Every day, almost 20,000 Hartford HealthCare employees come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut's most comprehensive healthcare network.

The creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole, rather than a single member organization.

With the creation of our new umbrella organization we now have our own identity with a unique payroll, benefits, performance management system, service recognition programs and other common practices across the system.

Integrated Care Partners (ICP) is a physician-led, clinically integrated health care network whose mission is to assist our members in providing the highest quality care at the most reasonable cost for our patients in the current, rapidly changing medical environment.

Position Summary:

The Utilization Management Specialist is an integral part of the Care Management team whose focus is on performing a timely level of care assessment ideally at the immediate point of entry into the health system to ensure that patients are assigned the most appropriate patient class based on their clinical needs incorporating the judgment of their provider. The UMS is able to work autonomously and swiftly, managing a high volume of complex cases across all HHC system hospitals.

Position Responsibilities:

  • Apply standard criteria and guidelines to assist in determining and/or to validate the patient class assigned by the provider.

  • Document review and findings as well as any additional information relevant to the case as directed and appropriate.

  • Partner with the Emergency Department and/or the Admitting Provider to ensure the patient class assigned is appropriate given the patient's clinical presentation.

  • Act as a resource and subject matter expert to the Emergency Department and/or the Admitting Provider on aspects of patient class and level of care determination.

  • Escalate cases to designated Physician Advisor resource when assigned level of care is not appropriate and Emergency Department or Admitting Provider is unwilling to consider recommendations for alternative.

  • Maintain knowledge of industry standards and regulatory requirements which influence patient class and level of care determinations.

  • Provide education sessions to constituency groups as needs are identified and/or as requested.

  • Support needs of the department in the event of a critical demand or a decrease in volumes by performing a review of work ques, crafting appeal responses, etc.

  • Ensure any information critical to the care and progression of the patient gleaned during the review process is relayed to the Care Manager responsible for the patient.

  • Complete assignments to demonstrate expert knowledge of criteria as requested.

  • Other duties as assigned.

Education: Registered Nurse with a BSN in Nursing

Experience: At least five (5) years of relevant clinical experience. Acute care or managed care utilization review is preferred.

Licensure, Certification, Registration: Current State of Connecticut RN license


Knowledge, Skills and Ability

Requirements:
  • Familiarity with clinical care

  • Able to influence and negotiate

  • Critical thinking, astute assessment and confident in decision making

  • Strong interpersonal and communication skills

  • Knowledge of Interqual or equivalent criteria and reimbursement guidelines

We take great care of careers.

With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving employees-- we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment.


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Utilization Management Specialist

William Backus Hospital