Full time
Day Shift
The Utilization Management (UM) Registered Nurse is responsible for reviewing medical services and treatment plans to ensure the delivery of appropriate, cost-effective, and high-quality patient care. Using established clinical guidelines, regulatory requirements, and health plan policies, the UM RN collaborates with providers, interdisciplinary care teams, and patients to support optimal health outcomes while promoting the efficient use of healthcare resources.
Key Responsibilities
Conduct concurrent utilization reviews to determine and validate the appropriate level of care using established criteria, including InterQual and Milliman guidelines.
Initiate, manage, and track admission authorizations and payer communications.
Review and monitor insurance denials, support appeals processes, and identify opportunities for utilization management process improvements.
Collaborate with physicians, case managers, and interdisciplinary care teams to optimize care plans and facilitate timely, effective discharge planning.
Ensure clinical documentation accurately reflects severity of illness, medical necessity, and appropriate resource utilization.
Partner with Finance, Health Information Management (HIM), Admitting, and other key departments to support utilization management activities and organizational goals.
Work closely with care coordination teams to promote high-quality, patient-centered, and cost-effective outcomes.
Maintain compliance with regulatory, accreditation, and payer requirements.
Required
Graduate of an accredited School of Nursing.
Current, unrestricted Connecticut Registered Nurse (RN) license.
Preferred
Bachelor of Science in Nursing (BSN).
Three (3) or more years of Utilization Management, Utilization Review, Case Management, or related experience in an acute care hospital setting.
Experience utilizing InterQual and/or Milliman clinical criteria.
Position Highlights
Full-time, 40 hours per week
Hybrid work schedule
About Saint Francis Hospital
Saint Francis Hospital has been a trusted healthcare leader in Connecticut since 1897. As a member of Trinity Health Of New England and Trinity Health, one of the nation's largest Catholic healthcare systems, Saint Francis is committed to delivering exceptional patient care, advancing medical innovation, and serving the community. Saint Francis Hospital is a 617-bed Level I Trauma Center and major teaching hospital offering a comprehensive range of specialized services. Notable programs and affiliated entities include the Comprehensive Women's Health Center, the Connecticut Joint Replacement Institute, and Smilow Cancer Hospital. Through a commitment to excellence, compassion, and innovation, Saint Francis continues to provide high-quality care to patients across the region.
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
Trinity Health is one of the largest not-for-profit, Catholic health care systems in the nation. It is a family of 123,000 colleagues and nearly 27,000 physicians and clinicians caring for diverse communities across 26 states. Nationally recognized for care and experience, the Trinity Health system includes 88 hospitals, 135 continuing care locations, the second largest PACE program in the country, 136 urgent care locations and many other health and well-being services. Based in Livonia, Michigan, its annual operating revenue is $21.5 billion with $1.4 billion returned to its communities in the form of charity care and other community benefit programs.
