Utilization Management Registered Nurse RN

About the role

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.

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.

Requirements

• Graduate of an accredited School of Nursing.
• Current, unrestricted Connecticut Registered Nurse (RN) license.

Qualifications

• Bachelor of Science in Nursing (BSN) (preferred).
• Three (3) or more years of Utilization Management, Utilization Review, Case Management, or related experience in an acute care hospital setting (preferred).
• Experience utilizing InterQual and/or Milliman clinical criteria (preferred).

Schedule

Full-time, 40 hours per week. Hybrid work schedule.

About the organization

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.