Clinical Review Nurse

  • Emblem Healthcare-Home Health & Hospice
  • $80,200.00 - 103,520.00 / Year *
  • 11 Hatters Ln, Farmington, CT 06030
  • Full-Time



Check out similar listings!

Loading some great jobs for you...




ConnectiCare is a leading health plan in the state of Connecticut. ConnectiCare s mission is to make it easy for members to get the care they need. A local company for over 35 years, ConnectiCare has a full range of products and services for businesses, municipalities, individuals and those who are Medicare-eligible. A subsidiary of EmblemHealth, ConnectiCare leads the individual and small group markets in the state, and is ranked among the top commercial health plans in the nation, according to the National Committee for Quality Assurance.

We re looking for individuals who want to make a difference in the communities we serve. If you want to join a local team and help change the way health care is delivered, ConnectiCare is the place for you.

Purpose: Professional clinician (RN/SW), who in collaboration with health care providers, supports and enables members to manage their physical, environmental and psycho-social concerns, understand and appropriately utilize their health plan benefits and remain safe and independent in their home or current living environment. As part of a multi-disciplinary care team providing care and utilization management, with responsibilities that include care coordination, performing telephonic or face-to-face assessments of members health care needs, identifying gaps in care and needed support, administering/coordinating authorization and concurrent review processes and coordinating implementation of interventions.

Key Accountabilities:

  1. Act as the clinical coordinator collaborating with members, caregivers, providers, TPH multi-disciplinary team, and health care and community resources to evaluate member needs through a variety of assessments (care and utilization management) to identify areas of (medical, financial, environmental, health insurance benefit, psycho-social, caregiving) concern and potential gaps in care.
  2. Based on areas of concern, identify appropriate goals, strategies and interventions that may include referrals, authorizations, health education, activation of community based resources, life planning, or program/agency referrals.
  3. With the member, caregiver, provider(s) and TPH multidisciplinary team, develop, communicate and evaluate medical management strategies and interventions including potential for alternative solutions to ensure high quality, cost effective continuum of care.
  4. Work collaboratively with all stake holders to ensure knowledge of the action plan, including participation in telephonic and face-to-face case conferences when appropriate.
  5. Act as the member s advocate and liaison by completing or facilitating interventions with providers and/or private, non-profit, and governmental agencies.
  6. Ensure that all TPH processes and reporting are compliant with all applicable federal and state regulations, and NCQA and ConnectiCare standards.
  7. Participate in delegation oversight and monitoring activities, as required.
  8. Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making coverage determinations and care management recommendations.
  9. Review and investigate member and provider requests to determine appropriate utilization of benefits and/or claim adjudication.
  10. Enter and maintain documentation in the TPH platform meeting defined timeframes and performance standards. Communicate authorization decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, and NCQA and ConnectiCare standards.
  11. Maintain an understanding of TPH principles, program objectives and design, implementation, management, monitoring, and reporting.
  12. Identify quality, cost and efficiency trends and provide solution recommendations to Supervisor/Manager.
  13. Actively participate on assigned committees.
  14. Perform other related projects and duties as assigned.



Technical Knowledge & Experience:

  1. For RNs: Associate s degree or Bachelor s degree in Nursing with 3-5 years of clinical nursing experience. Valid RN License in the State of CT without restriction. May require a CME accreditation in specific specialties.
  2. For SWs: Bachelor s degree in Social Work, Gerontology or a related human services field and 2 years clinical experience. Master s degree or licensure preferred. Knowledge of CT Dept of Social Services (DSS) benefits, programs and resources required.
  3. Prior case and/or utilization management/care coordination and managed care experience preferred.
  4. Certification in utilization or care management preferred.
  5. Strong oral and written communication, organizational, and interpersonal skills required. Trained in the use of Motivational Interviewing techniques a plus.
  6. Experience working in physician practice and/or with electronic medical records preferred.
  7. Proficiency with the use of mobile technology (Smartphone, wireless laptop, etc.).
  8. Previous system user experience in a highly automated environment and strong personal computer literacy on Windows products required.
  9. Bilingual in English/Spanish or English/Polish a plus.
  10. Strong cross-group collaboration, teamwork, problem solving, and decision making skills
  11. Presentation, analytical and negotiation skills.
  12. Manage a flexible work schedule to meet member and/or caregiver and departmental scheduling needs.

ConnectiCare is an equal opportunity employer. M/F/D/V



Associated topics: domiciliary, maternal, mhb, nurse, nurse clinical, recovery, registered nurse, surgery, tcu, transitional


* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.