Clinical Resource Management Nurse (RN) - Case Coordination
Company: Manchester Memorial Hospital
Location: New Britain
Posted on: January 18, 2026
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Job Description:
Location Detail: MMH-71 Haynes Street (10627) Shift Detail: All
shifts available Work where every moment matters. Every day, over
40,000 Hartford HealthCare colleagues come to work with one thing
in common: Pride in what we do, knowing every moment matters here.
We invite you to become part of Connecticut’s most comprehensive
healthcare network. The Greater Manchester Region has approximately
2,500 employees. It includes Manchester Memorial Hospital, a
249-bed community hospital, Rockville General, a campus of
Manchester Memorial Hospital, a 102-bed facility, a large
multispecialty provider group and visiting nurse services. The
Greater Manchester Region serves a region of 300,000 people in 19
towns. POSITION SUMMARY: The Utilization Review Case Manager (UR
CM) works in collaboration with the physician and interdisciplinary
team to support the underlying objective of enhancing the quality
of clinical outcomes and patient satisfaction while managing the
cost of care and providing timely and accurate information to
payers. The role integrates and coordinates utilization management
and denial prevention by focusing on identifying and removing
unnecessary and redundant care, promoting clinical best practice,
and ensuring all patients receive “the right care, at the right
time, and in the right setting”. The UR CM is responsible for
preoperative, concurrent, and retrospective reviews in accordance
with the utilization management plan. The UM CM ensures the
appropriate status and level of care is determined and ensures
accurate assessment of medical necessity, thus appropriate
reimbursement. Performs duties in support of ECHN mission to ensure
the highest quality of patient care in an economically sound and
efficient manner. Qualifications EDUCATION/CERTIFICATION: •
Bachelor’s Degree in Nursing or a related field. • Current
licensure as an RN. EXPERIENCE: • 2 – 3 years’ experience in case
management, discharge planning, and/or progression of care in the
acute-care setting. • Minimum of 1 year Utilization Review
experience preferred via industry clinical standards, i.e.,
InterQual, Milliman Care Guidelines. COMPETENCIES: • Comprehensive
knowledge of the health care reimbursement system. • Demonstrated
skill in creative problem-solving, facilitation, collaboration,
coordination, and critical thinking. • Excellent demonstrated oral,
written and communication skills. • Proficiency in the use of work
processing and spreadsheet application. ESSENTIAL DUTIES and
RESPONSIBILITIES: Disclaimer: Job descriptions are not intended,
nor should they be construed to be, exhaustive lists of all
responsibilities, skills, efforts or working conditions associated
with the job. They are intended to be accurate reflections of the
principal duties and responsibilities of this position. These
responsibilities and competencies listed below may change from time
to time. Eastern Connecticut Health Network reserves the right to
change or assign other duties and responsibilities to this position
• Conducts concurrent and retrospective review(s) utilizing
InterQual (IQ), Milliman Care Guidelines (MCG), or in accordance
with CMS rules and regulations for medical necessity criteria to
monitor appropriateness of admissions and continued stays, and
documents findings based on department policy/procedure; refers
appropriate cases to Physician Advisor for recommendation(s). •
Ensures order in chart/EMR and status coincides with the IQ or MCG
review or CMS rules and regulations for appropriate Level of Care
and status on all patients through collaboration with Case Manager.
• Demonstrates thorough knowledge in the application of medical
necessity criteria. • Assess the safest and most efficient care
level based on severity of illness, comorbidities and
complications, and the intensity of services being delivered. •
Utilizes appropriate payer criteria to provide recommendation(s) to
the attending physician • Communicates payor criteria and issues on
a case-by-case basis with multidisciplinary team and follows up to
resolve problems with payors as needed; initiates peer to peer when
appropriate. • Contacts the attending physician for additional
information if the patient does not meet the appropriate medical
necessity criteria or in accordance with CMS rules and regulations
for continued stay. • Escalates review timely to physician advisor
timely for lack of medical necessity and/or status discrepancies. •
Educates physicians and interdisciplinary team regarding approved
criteria practice guidelines, level of care, length of stay, and
alternative treatment options. • Supports multi-disciplinary
strategies to reduce length of stay, reduce resource consumption,
and achieve positive patient outcomes. • Collaborates with
multidisciplinary team members to identify and implement strategies
to ensure appropriate utilization and achieve positive patient
outcomes. • Demonstrates knowledge of target length of stay and
GMLOS for diagnosis by actively monitoring length of stay timeframe
and implementing measures to achieve targets. • Prevents denials by
providing timely clinical reviews to payers for authorization of
services provided and completes case review for claim
reimbursement. • Reviews outlier cases to determine level of care
and clinical appropriateness. • Assists as appropriate in the
collection and reporting of financial indicators including length
of stay, approved, denied, and avoidable days, and resource
utilization. • Demonstrates skill in communicating with physicians
the necessary documentation to demonstrate medical necessity. •
Utilizes data to drive decisions related to utilization management
for assigned patients, including fiscal and clinical data. •
Responsible for yearly re-education on industry standard criteria,
i.e., InterQual/Milliman Care Guidelines. • Collects and analyzes
data to provide information regarding system barriers to care
delivery, patient care outcomes, resource trends and patterns. •
Advocates for, supports and protects the rights of patients.
Promptly reports any potential compromise of rights to appropriate
individual (s). • Identifies quality, infection control,
utilization, and risk management issues with referrals to
appropriate committee/personnel. • Continuously pursue excellence
in meeting the needs and expectation of all customers (patients,
families, inter-disciplinary team members, payors, screener,
liaisons and outside services and agencies. We take great care of
careers With locations around the state, Hartford HealthCare offers
exciting opportunities for career development and growth. Here, you
are part of an organization on the cutting edge – helping to bring
new technologies, breakthrough treatments and community education
to countless men, women and children. We know that a thriving
organization starts with thriving colleagues we provide a
competitive benefits program designed to ensure work/life balance.
Every moment matters. And this is your moment
Keywords: Manchester Memorial Hospital, Pawtucket , Clinical Resource Management Nurse (RN) - Case Coordination, Healthcare , New Britain, Rhode Island
