Clinical Utilization Navigator (RN)

LCS Lifespan Corporate Services d/b/a Brown University Health; United States; On-site; USD 80,000 - 161,000; Full time

Job summary

Brown University Health in Providence, RI seeks an experienced RN for a Utilization Review role focusing on medical necessity, level of care and prior authorizations with third-party payers. You will collaborate with physicians and the Utilization Review Committee to ensure safe, high-quality, cost-effective patient care.

The position requires strong nursing credentials, RN licensure in Rhode Island, familiarity with InterQual criteria, and experience in discharge planning and appeals.

Qualifications

• RN license in Rhode Island with current practice rights.
• Bachelor’s degree in Nursing; master’s preferred.
• Knowledge of utilization review and discharge planning.
• Familiarity with Medicare/ payer guidelines.

Responsibilities

• Apply InterQual level of care screening within one business day of admission.
• Collaborate with physicians to resolve care level discrepancies.
• Provide documentation to third party payers for authorization.
• Educate team on Medicare regulations and HINN processes.
• Coordinate with Care Coordination to plan discharge readiness.
• Identify opportunities to improve patient flow and reduce delays.
• Conduct concurrent reviews and expedited appeals as needed.
• Maintain accurate records and communicate with stakeholders.

Skills

Analytical skills

Interpersonal skills

Collaborative approach

InterQual knowledge

Microsoft Office

Keyboarding

Education

Bachelor’s degree in Nursing

Master’s Degree preferred

CPHM certification desired

Tools

InterQual criteria

Job description

Brown University Health in Providence, RI seeks an experienced RN for a Utilization Review role focusing on medical necessity, level of care and prior authorizations with third-party payers. You will collaborate with physicians and the Utilization Review Committee to ensure safe, high-quality, cost-effective patient care.

The position requires strong nursing credentials, RN licensure in Rhode Island, familiarity with InterQual criteria, and experience in discharge planning and appeals.