Utilization Management RN
Reporting to the Yale Health Medical Director, the Utilization Management RN is responsible for identifying opportunities to optimize the utilization of healthcare resources through the administration of the benefit for members of the Yale community.
The Utilization Management RN is responsible for the review of pre-certification requests for medical necessity, referring to the Medical Director those that require additional expertise; review clinical information for concurrent reviews, extending or limiting the Length of Stay for inpatients as appropriate. Manages the process of request for authorizations (inpatient/outpatient, DME and ancillary services), from member or provider and communicates in a timely manner when the decision has been made. Provides appropriate consultation and referral to clinical staff and Care Management personnel. Provides advice and counsel to referral and claims staff for authorization. Notify claims when there is a possible coordination of benefits issue due to other insurance or automobile accident. Work with referral team on out of area approvals and second opinions and transition care issues to Care Management as appropriate. Coordinate and collaborate with Yale-New Haven Hospital and Yale Health Care Managers for discharge planning recommendations as appropriate.
Schedule: Full-time, generally 37.50 hours per week M-F 8:30 am - 5:00 pm. Part-time schedules will be considered. This is a temporary role with an anticipated end date of August 31, 2020.
- Performs physical assessments of patients, including triage duties and advises on treatment or course of action.
- Identifies and evaluates nursing services problems and develops and implements appropriate programs and services, including assessing staffing needs and arranging coverage as needed.
- Develops, implements, and manages nursing care plans in collaboration with physicians.
- Instructs patients and families in proper treatment and advises patients on health maintenance and disease prevention.
- Provides leadership, guidance, direction to clinical staff, and collaborates with nursing at all levels.
- Determines standards for quality assurance and infection control procedures; trains staff in universal and isolation precautions in the area of infection control.
- Performs diagnostic and therapeutic measures in collaboration with physicians.
- Evaluates the quality and effectiveness of nursing practice and nursing services.
- Records patients’ medical histories and symptoms, performs diagnostic tests and analyzes results, operates medical machinery, administers treatment and medications, and coordinates with patient follow-up and rehabilitation; assures all procedures for maintaining patient confidentiality are maintained per HIPAA guidelines.
- May perform other duties as assigned.
Required Education and Experience
Bachelor’s Degree in Nursing and two years’ experience or an equivalent combination of education and experience.
Required Skill/Ability 1:
Demonstrated ability to apply detailed and thorough understanding of the healthcare insurance benefits package, identifying cases and situations in which clarification and timely decision making are necessary.
Required Skill/Ability 2:
Self-directed with the ability to work independently and consistently utilize a high level of initiative in order to manage work. Superior time management skills.
Required Skill/Ability 3:
Demonstrated ability to problem solve complex, multifaceted, emotionally charged situations. Demonstrated ability to effectively manage relationships and articulate issues and outcomes to staff and patients.
Required Skill/Ability 4:
Demonstrated ability to work collaboratively with all members of the healthcare and healthcare support team.
Required Skill/Ability 5:
Excellent attendance, reliability and punctuality. EMR proficiency.
Preferred Education, Experience and Skills:
Experience with Utilization Management.
Required Licenses or Certifications
Licensure as Registered Nurse in the State of Connecticut or Connecticut license eligible. Current CPR certification.
Background Check Requirements
All candidates for employment will be subject to pre-employment background screening for this position, which may include motor vehicle, DOT certification, drug testing and credit checks based on the position description and job requirements. All offers are contingent upon the successful completion of the background check. Please visit www.yale.edu/hronline/careers/screening/faqs.html for additional information on the background check requirements and process.
The intent of this job description is to provide a representative summary of the essential functions that will be required of the position and should not be construed as a declaration of specific duties and responsibilities of the particular position. Employees will be assigned specific job-related duties through their hiring departments.
Affirmative Action Statement:
Yale University considers applicants for employment without regard to, and does not discriminate on the basis of, an individual’s sex, race, color, religion, age, disability, status as a veteran, or national or ethnic origin; nor does Yale discriminate on the basis of sexual orientation or gender identity or expression. Title IX of the Education Amendments of 1972 protects people from sex discrimination in educational programs and activities at institutions that receive federal financial assistance. Questions regarding Title IX may be referred to the University’s Title IX Coordinator, at TitleIX@yale.edu, or to the U.S. Department of Education, Office for Civil Rights, 8th Floor, Five Post Office Square, Boston MA 02109-3921. Telephone: 617.289.0111, Fax: 617.289.0150, TDD: 800.877.8339, or Email: firstname.lastname@example.org.
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