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Utilization Management Nurse

Company: Neighborhood Health Plan of RI
Location: Providence
Posted on: October 14, 2020

Job 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.

This role is on the Medicaid Team as an  Skilled Nursing Reviewer.

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

Other duties as assigned

Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and  the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents


Graduate from an Accredited School of Nursing

Active and unrestricted Registered Nurse License in state of Rhode Island (Consideration will be given to individuals without current RI license. Must provide documentation confirming RI RN application within 24 hours of offer)

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


Bachelor of Science in Nursing (BSN) from an accredited school of nursing

Three (3) years of experience in utilization management

Utilization Review or Case Management Certification

Previous experience in behavioral health and/or long term care environment

Bilingual (English/Spanish)

Core Company-Wide Competencies:

Communicate Effectively

Respect Others & Value Diversity

Analyze Issues & Solve Problems

Drive for Customer Success

Manage Performance, Productivity & Results

Develop Flexibility & Achieve Change

Job Specific Competencies:

Build Relationships & Cultivate Networks

Influence & Negotiate

Attend to Detail & Improve Quality

Exercise Sound Judgement & Decision Making

Flexible Work Arrangement:

Yes, with prior approval of supervisor

Telecommuting Arrangement:

Yes with prior approval of supervisor, within a schedule that meets the needs of the company and allows for meeting continued performance expectations

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.

Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at

Keywords: Neighborhood Health Plan of RI, Providence , Utilization Management Nurse, Other , Providence, Rhode Island

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