• Utilization Management Nurse

    Job Locations US-RI-Smithfield
    Req No.
    NHPRI Department
    804 - Utilization Management
    Regular Full-Time
  • Overview

    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.


    • 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
    • Identifies high-risk members and initiates appropriate referrals to case management. Alerts appropriate departments of possible primary or secondary insurance coverage.
    • 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
    • Utilizes the case management software system to document any outreach activities associated with member enrollment in the Transitions of Care program, including educating members on how to better self manage their condition in both an acute or chronic stage including transitioning from hospital to home
    • 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
    • Three (3) years of experience in acute care or hospital setting
    • Three (3) years of experience in utilization management
    • Previous experience performing utilization management for Medicare Advantage, Managed Care, Medicaid, Duels and Commercial Lines of Business
    • Previous experience with Medical Review guidelines and CMS requirements
    • Demonstrated knowledge in medical practices, utilization management processes/standards, insurance benefit structures, managed care and clinical documentation
    • Detailed knowledge of medical-necessity decisions, including inpatient, sub-acute/skilled care, outpatient care, hospice care, and home health care
    • Advanced level experience utilizing Health Care Management/Authorization Software, Electronic Health Record (EHR) and Microsoft Office
    • 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
    • Utilization Review or Case Management Certification
    • Previous experience in behavioral health and/or long term care environment
    • Bilingual (English/Spanish)

    Organizational Competencies:

    • Judgment and Decision Making
    • Gets Results
    • Collaboration and Teamwork
    • Business Awareness
    • Customer Focus

    Job Specific Competencies:

    • Attention to Detail
    • Flexibility & Achieving Change
    • Organizational Savvy
    • Planning & Organizing
    • Problem Solving & Analysis

    Telecommuting Arrangement

    • Yes. Begins after 6 months of employment

    Flexible Work Arrangement

    • Yes. Ability to work weekends as needed.

    Travel Expectations:

    • Ability to travel within local region required

    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 recruiting@nhpri.org


    Neighborhood is an EOE M/F/D/V and an E-Verify Employer


    Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
    Share on your newsfeed

    Need help finding the right job?

    We can recommend jobs specifically for you! Click here to get started.