Utilization Review Nurse Coordinator (40 Hour)

Do you want to make a difference while participating in a dynamic and reciprocal health care environment in the public sector? If so, we have an excellent opportunity to join our team!

Capitol Region Mental Health Center (CRMHC) seeks qualified a individual for the position of Utilization (UR) Nurse Coordinator (PCN 26342), for our Quality Improvement (QI) unit located at 500 Vine Street, Hartford. This position is full-time, first shift, 8:00am to 4:30pm, and Monday through Friday (40 hours per week).

The UR Nurse Coordinator reports to the QI Director where they will:

• Coordinate the review of clinical documentation;
• Oversee the departments reimbursement of clinical services activities;
• Supervise and collaborate with the UR Nurses to ensure clinical intakes, psychosocial assessments and risk evaluations are conducted to the highest standards.

CRMHC is a community based mental health center, operated by the Connecticut Department of Mental Health and Addiction Services, which provides an array of innovative clinical and community support services to individuals with a psychiatric disability, in many cases with co-occurring problems of substance abuse.

Capitol Region Mental Health Center and the DMHAS-Funded Mental Health Programs serve adults with serious psychiatric disabilities or the co-occurring disorders of psychiatric illness and substance use, 18 years and older who reside in Hartford (Catchment Area 23), West Hartford, Farmington, Avon, Canton and Simsbury (Catchment Area 18).

This position will be filled in accordance with contractual language, reemployment, SEBAC, transfer, promotion and merit employment rules. In order to be considered for this job opening, you must meet the Minimum Qualifications as listed on the job opening. You must specify your qualifications on your application.

The minimum experience and training requirements must be met by the close date on the job opening, unless otherwise specified.

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 Office of Protection and Advocacy and the Department of Developmental Services this class is accountable for performing investigations of abuse, neglect and death in individuals with intellectual disabilities including individuals under the care of the Department of Developmental Services.

WORKING LEAD (REGULATORY) : Coordinates work flow 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.

ADVANCED WORKING LEVEL (INVESTIGATORY): Conducts complex investigations into allegations of abuse or neglect of individuals with intellectual disabilities; conducts complex investigations into cases where a death has resulted of an individual with  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; may provide information and assistance to the Independent Mortality Review Board or Fatality Review Board for Persons with Disabilities; maintains records and documentation; reviews medical records for pertinent information related to investigations; may testify in court proceeding; performs related duties as required.

DEPARTMENT OF VETERANS AFFAIRS: Coordinates activities of care team, plans and schedules meetings, tracks input and attendance; insures 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; considerable knowledge of standards of medical care; considerable interpersonal skills; considerable oral and written communication skills; considerable ability to analyze individual profiles and progress charts; some supervisory ability.

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

INVESTIGATORY: Considerable knowledge of statutes, policies and procedures governing the care and treatment of individuals with intellectual disabilities; considerable knowledge of problems and needs of individuals with  intellectual disabilities; considerable knowledge of various types of residential placement facilities; knowledge of investigatory methods and techniques; considerable interviewing skills; ability to research and analyze data; considerable skills in the preparation of extensive written reports.

DEPARTMENT OF VETERANS AFFAIRS: Knowledge of Minimum Data Set process in a long term care setting and coordination of an interdisciplinary team; ability to utilize computer software.

Five (5) years of experience as a registered professional nurse.

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 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 or Intellectual Disabilities.

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.

A Bachelor's degree in nursing may be substituted for one (1) year of the General Experience.

• Experience providing and documenting services to clients experiencing chronic and persistent mental illness
• Experience teaching and providing guidance to providers on how to improve the level of quality in their documentation
• Experience integrating evidence based treatment into mental health service delivery
• Experience providing supervision around documentation and/or treatment planning
• Experience working with and creating Microsoft Excel spreadsheets, including managing data, formatting, and setting up formulas

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

AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER

The State of Connecticut is an equal opportunity/affirmative action employer and strongly encourages the applications of women, minorities, and persons with disabilities.