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Utilization Management Nurse New

Smithfield, RI


Hiring Company

Neighborhood Health Plan of Rhode Island

Positions Available

Full Time

Apply now

Position Description


The Utilization Management Nurse works collaboratively with the health care team to ensure proper utilization of medical services, procedures and care settings for individual members by assessing member needs and identifying solutions that promote quality and cost-effective care in the transition of care from the acute setting.  The Utilization Management Nurse determines medical appropriateness for inpatient and outpatient services by evaluating medical information and applying established national criteria benefit determination, medical guidelines and compliance with state mandated regulations based on InterQual and other organizational tools. This includes concurrent reviews of inpatient/outpatient services, sub-acute care and prior-authorization reviews.


Responsibilities include, but are not limited to the following: 

  • Assess member’s needs, performing pre-certification, concurrent and retrospective review of out-patient and in-patient services, including onsite at various contracted hospitals and/or telephonic using established criteria, plan benefit guidelines, and clinical judgment to determine appropriateness of medical services, procedures and care setting
  • Refers and discusses complex case or cases that do not meet established criteria and guidelines with the Physician Advisor
  • Collaborates with staff, physicians, care/service coordinators, and medical director to coordinate and provide the level of care necessity to meet the member’s health need
  • Ensures that all company policies relative to privacy and confidentiality are followed and that any information either obtained or disclosed is done in confidence.
  • Evaluates requests for outpatient services such as home care, therapies and DME and makes authorization decisions based on medical necessity, benefit coverage, and the ongoing needs of the individual member
  • Reviews requests for conditional benefits and utilizes established company clinical guidelines to determine medical necessity. Presents to Physician Advisor for authorization decision, as necessary
  • Recognizes Continuity of Care and Coordination of Benefits utilization requirements
  • Supports the referrals to case management of complex cases through use of the case management software system
  • Collaborates with peers internally and externally to continually ensure member’s health care needs are being met in accordance with the benefit plans and through identification of agreed upon alternative services.
  • Documents cost savings that may result from medical review process (i.e. bed downgrades, change to observation status, alternative setting, etc.)
  • Meets department and regulatory standards for accuracy, proficiency and documentation in order to communicate decisions and plan of care in an appropriate and timely manner, and to ensure appropriate reimbursement in the Claims adjudication system
  • Follows and maintains compliance with regulatory agency requirements and participate in continues quality improvement activities
  • Attends all required trainings and management-identified meetings in person. In certain circumstances, the employee may be allowed to conference in, at the discretion of the management team


  • Graduate from an Accredited School of Nursing
  • Active and unrestricted Registered Nurse License in state of Rhode Island
  • Three (3) years of experience in acute care, hospital setting or long term care admission assessments
  • Previous experience performing utilization management for Medicare Advantage, Managed Care, Medicaid, Duals and Commercial Lines of Business
  • Previous experience with Discharge Planning, Medical Review guidelines and/or CMS requirements
  • Demonstrated knowledge in medical practices, utilization management processes/standards, insurance benefit structures, managed care and clinical documentation
  • Detailed knowledge of clinical guidelines or medical-necessity decisions relating to inpatient, sub-acute/skilled care, outpatient care, hospice care, or home health care
  • Advanced level experience utilizing Health Care Management/Authorization Software, or Electronic Health Record (EHR)
  • Ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families
  • Strong communication (verbal and written) organizational, multitasking and teamwork skills
  • High level of professionalism and integrity with adherence to all confidentiality requirements
  • Ability to work weekends
  • Ability to provide rotational coverage as needed


Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.


Apply now

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