State of Connecticut Executive Branch

In a state agency this class is accountable for coordinating a utilization review program which promotes effective cost recovery, quality of care and/or compliance with relevant federal and state laws, regulations and standards.

In the Department of Developmental Services this class is accountable for performing investigations of abuse, neglect and death in individuals with an intellectual disability including individuals under the care of the Department of Developmental Services.

• Working Lead: The incumbent is assigned full time lead responsibility over assigned staff in a work unit.
• Advanced Working Level: In the Department of Developmental Services, this class is reserved for incumbents who are responsible for applying professional nursing knowledge in the investigatory functions of the agency regarding individual’s health and safety. The work performed is in accordance with PA-03-146.
• The Department of Veterans Affairs will have a position assigned to the class that functions as coordinator and facilitator of the Minimum Data Set (MDS) program.

• Coordinates workflow and determines priorities to assure highest quality of care with efficient utilization of available services;
• Schedules, assigns, oversees and reviews work;
• Establishes and maintains program protocols and procedures;
• Provides staff training and assistance;
• Conducts or assists in conducting performance evaluations;
• Acts as liaison with other operating units, agencies and outside officials regarding program policies and procedures;
• Prepares reports and correspondence;
• Assesses, evaluates and monitors documentation of all hospital disciplines when performing case reviews;
• Attends professional workshops, seminars and in-service training;
• 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;
• May review medical records and compile documents for case presentations;
• May provide pre-certification for and coordination of inmates admitted to and discharged from acute care facilities;
• May lead an inspection team in IPR/UR and licensing review functions;
• May conduct entrance and exit interviews of care providers;
• 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 testify in court;
• 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 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;
• Performs related duties as required.

• Conducts complex investigations into allegations of abuse or neglect of individuals with an intellectual disability;
• 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;
• Reviews medical care that was provided to individuals;
• Assists in the investigation to determine if the death is a result of abuse or neglect;
• Participates in the reviews of events, overall care, quality of life and medical care preceding a death;
• Works cooperatively with State and local police, State's Attorneys and other protective services organizations;
• Interviews alleged victims, direct care providers, families and other potential witnesses;
• Prepares comprehensive, complex investigative reports;
• Maintains records and documentation;
• Reviews medical records for pertinent information related to investigations;
• May provide information and assistance to the Independent Mortality Review Board or Fatality Review Board for Persons with Disabilities;
• May testify in court proceeding;
• Performs related duties as required.

• Coordinates activities of care team, plans and schedules meetings, tracks input and attendance;
• Ensures outcome of process is accurate document for care planning;
• Audits process according to utilization guidelines and ensures process is completed within appropriate regulatory time frames;
• Trains all Health Care Team members on Resident Assessment Instrument (RAI) care planning system;
• Acts as resource to all areas involved in Minimum Data Set (MDS) process;
• Ensures compliance with state statutes, federal Veterans Affairs regulations and state Department of Veterans Affairs policies and procedures;
• Monitors and manages timely electronic transmission of MDS program data;
• Routinely conducts chart audits and maintains log of deficiencies and discrepancies;
• Identifies errors in coding of MDS and RAI forms during completion process;
• Communicates to leadership and interdisciplinary team members any changes to directives and guidelines;
• Enters MDS data into information system;
• Assures ongoing record documentation supports MDS and RAI coding;
• Develops plan of action to correct identified quality deficiencies;
• Performs related duties as required.

• Considerable knowledge of
  • principles, practices and current trends of nursing;
  • standards of medical care
• Considerable
  • interpersonal skills;
  • oral and written communication skills;
• Considerable ability to analyze individual profiles and progress charts;
• Supervisory ability.

• Considerable knowledge of
  • and ability to apply relevant state and federal laws, statutes and regulations;
  • regulations and standards pertaining to utilization review;
  • care and service delivery to injured workers.

• Considerable knowledge of
  • statutes, policies and procedures governing the care and treatment of individuals with an intellectual disability;
  • problems and needs of individuals with an intellectual disability;
  • various types of residential placement facilities;
• Knowledge of investigatory methods and techniques;
• Considerable
  • interviewing skills;
  • skills in the preparation of extensive written reports;
• Ability to research and analyze data.

• Knowledge of Minimum Data Set process in a long-term care setting and coordination of an interdisciplinary team;
• Ability to utilize computer software.

REGULATORY: Two (2) years of the General Experience must have been in the assessment of the quality and propriety of health care services as required by Joint Commission on Accreditation of Healthcare Organizations (JCAH) and/or Medicare and Medicaid standards and regulations at the level of Utilization Review Nurse.

INVESTIGATORY: Two (2) years of the General Experience must have been working with persons with behavioral health disabilities or an intellectual disability.

DEPARTMENT OF VETERANS AFFAIRS: Two (2) years of the General Experience must have been in the review and assessment of individuals in a long-term care setting.

• Incumbents in this class must possess and retain a current license as a registered professional nurse in Connecticut.
• Incumbents in this class may be required to travel.