Clinical Utilization & Care Management Nurse

Lifespan; Providence (RI); On-site; USD 80,000 - 161,000; Full time

Job summary

Brown University Health at The Miriam Hospital in Providence, Rhode Island is seeking an experienced Utilization Review Nurse Manager to oversee clinical appropriateness, ensure payer authorizations, and optimize patient flow across care settings.

The role emphasizes collaboration with physicians, education of care teams on Medicare guidelines and regulatory requirements, and timely documentation to support high-quality, cost-effective care.

Qualifications

• RN licensure in Rhode Island or compact state
• Bachelor's in Nursing; Master's preferred
• Five years of clinical experience with utilization review or discharge planning
• Experience with InterQual criteria and Medicare regulations

Responsibilities

• Apply InterQual level of care criteria within one business day of admission
• Review admissions and communicate with third-party payers
• Educate care team on Medicare guidelines and HINN processes
• Collaborate with Care Coordination for discharge planning and patient flow
• Identify and reduce service delays and improve throughput

Skills

Nursing

Utilization review

Case management

InterQual criteria

Healthcare analytics

Education

Bachelor's degree in Nursing

Master's degree preferred

CPHM certification desirable

Tools

Microsoft Office

Outlook

EMR systems

Job description

Brown University Health at The Miriam Hospital in Providence, Rhode Island is seeking an experienced Utilization Review Nurse Manager to oversee clinical appropriateness, ensure payer authorizations, and optimize patient flow across care settings.

The role emphasizes collaboration with physicians, education of care teams on Medicare guidelines and regulatory requirements, and timely documentation to support high-quality, cost-effective care.