In a state agency this class is accountable for a full range of duties involving the assessment and review of health care delivery systems or medical cost containment activities and programs related to agency efforts to promote cost effective quality of care of cost containment in accordance with various federal and/or state statutes, regulations and guidelines.
Works under the general supervision of a Utilization Review Nurse Coordinator, Nurse Consultant or other employee of a higher grade.
EXAMPLES OF DUTIES:
Performs a variety of duties related to review of various types of health and medical care delivery and reimbursement systems; participates in utilization review and/or quality assurance programs; conducts various types of case reviews for quality and appropriate medical management, cost containment, peer review and rehabilitation; summarizes and analyzes data; prepares statistical reports; implements decisions in program according to revisions in standards; attends professional workshops, seminars and inservice training; maintains up to date knowledge of all changes in relevant discipline; may monitor agency and third party administrator files to oversee contractor handling; monitors personal injuries and medical costs to evaluate need for services billed for appropriate injuries; may review medical records of various health care eligibility, resource unit referral and/or compliance with federal funding provisions; performs related duties are required.
MINIMUM QUALIFICATIONS REQUIRED KNOWLEDGE, SKILL AND ABILITY:
Considerable knowledge of principles, practices and current trends in nursing; knowledge of and ability to apply relevant state and federal laws, statutes and regulations; knowledge of standards of practice of medicine and nursing as well as other health care disciplines; knowledge of regulations and standards pertaining to utilization review; knowledge of care and service delivery to injured workers; interpersonal skills; oral and written communication skills; ability to analyze patient profile and progress charts to evaluate proper care and treatment.
EXPERIENCE AND TRAINING:
Three (3) years experience as a registered professional nurse.
One (1) year of the General Experience must have been in hospital or institutional nursing, in a medical treatment facility, in rehabilitative or occupational nursing or providing medical review of insurance claims.
A Bachelor's degree in nursing may be substituted for one (1) year of the General Experience.
Incumbents in this class must possess and retain a license as a registered professional nurse in Connecticut.
Incumbents in this class may be required to travel.
This cancels the existing specification for the same class in the same Salary Group approved effective June 23, 1995. (Revised to expand usage statewide)