Utilization Review Nurse

Connecticut Children's

. Perform chart reviews to assess quality, timeliness, appropriateness, and level of care .

Posted 11/9/2026full-timeRemote • Connecticut • United StatesMid-LevelSenior💰 $42 - $64 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management, including conducting clinical reviews, applying level-of-care criteria, and collaborating with healthcare teams to optimize resource utilization. Proficient in navigating regulatory guidelines and utilizing software for documentation and reporting.

Highest-signal resume keywords

Bachelor Of Science In Nursing (BSN)Registered Nurse Licensure (Connecticut)Utilization Review ExperienceCase Management CertificationProficiency In Microsoft Office

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewUtilization ReviewLevel-Of-Care Criteria ApplicationDocumentation SupportData AnalysisResource UtilizationPediatric NursingCase ManagementDischarge PlanningRegulatory Compliance

Soft Skills

Excellent Communication SkillsCollaborationFlexibilityPrioritizationCritical Thinking

Tools & Technologies

Microsoft OfficeExcelEPICUtilization Software

Certifications & Qualifications

Case Management Certification

Industry Keywords

Utilization ManagementCMS GuidelinesHealthcare SettingCommunity ResourcesTreatment OptionsHome Health AvailabilityFunding OptionsPerformance ImprovementEvidence-Based ProtocolsHospital Case Management

About the role

Key responsibilities & impact

Perform chart reviews to assess quality, timeliness, appropriateness, and level of care
Conduct hospitalization reviews for Medicaid, other insurers, and self-pay patients using applicable guidelines
Gather clinical information for continued-stay utilization reviews with payers
Escalate cases for secondary review when appropriate
Perform concurrent and retrospective clinical reviews in compliance with regulations, policies, and timelines
Adhere to CMS utilization-review guidelines
Develop and implement strategies to reduce length of stay and resource consumption with discharge-planning staff
Identify and document progression-of-care barriers, avoidable days, and delays
Collaborate with hospital case management and care teams on resource utilization
Represent Utilization Management at committees as needed
Maintain utilization-software documentation for each patient
Educate physicians and qualified practitioners on documentation supporting the ordered level of care
Communicate reimbursement information and verify in-network and out-of-network benefits
Keep current on regulatory changes and national and local coverage determinations
Promote evidence-based protocols and order sets
Apply level-of-care criteria and clinical critical thinking to advocate for appropriate resource utilization
Collaborate with The Center team to coordinate appropriate care settings and timing
Identify care and resource gaps and address access issues
Support performance-improvement initiatives as a change agent, advocate, and resource person
Provide support to the hospital’s Utilization Management Committee and report key metrics to leadership as requested

Requirements

What you’ll need

Bachelor of Science in Nursing (BSN)
3 years’ nursing experience in a healthcare setting
Current State of Connecticut Registered Nurse licensure or nurse licensure compact (NLC), maintained thereafter
Working knowledge of interpreting and applying medical care criteria
Knowledge of community resources, treatment options, home health availability, funding options, and special programs
Proficiency in Microsoft Office Word
Ability to use and update Excel spreadsheets
Ability to navigate EPIC
Ability to function in a high-energy, fast-moving environment
Ability to maintain flexibility based on medical-unit acuity
Ability to prioritize caseload and manage multiple tasks
Ability to collaborate with various disciplines
Excellent written and verbal communication skills
Pediatric nursing experience preferred
Previous Utilization Review experience preferred
Previous Case Management or Discharge Planning experience preferred
Case Management Certification preferred

Benefits

Comp & perks

Medical insurance
Dental insurance
Vision insurance
Hospital-paid life insurance
Hospital-paid disability coverage
Paid time off
Leave programs
Education and training assistance
Retirement savings plan with hospital match
Employment assistance program