Nurse: Utilization Review & Care Coordination

Brown University Health; Providence (RI); On-site; USD 80,000 - 161,000; Full time

Job summary

Brown University Health seeks a registered nurse to manage utilization review, case management, and discharge planning within a hospital setting. You will ensure appropriate levels of care, obtain third-party authorizations, and educate care teams on Medicare and regulatory guidelines.

Responsibilities include applying InterQual criteria, addressing level-of-care discrepancies, and supporting expedited appeals when needed. Strong collaboration with physicians and care coordination is essential.

Qualifications

• Registered Nurse licensure in Rhode Island or equivalent licensure.
• Bachelor’s degree in Nursing; Master’s degree preferred.
• CPHM certification is highly desirable.

Responsibilities

• Oversees surveillance of medical necessity for patient care records and ensures proper authorizations.
• Applies InterQual criteria to admissions and resolves level-of-care discrepancies.
• Facilitates discharge planning and coordinates with third-party payers.
• Communicates with care teams and physicians regarding appropriate levels of care.
• Delivers notices of non-coverage and supports patient appeals where needed.
• Promotes timely throughput and reduces delays in patient flow.

Education

RN license Rhode Island

Bachelor’s in Nursing

Master’s degree preferred

CPHM certification desirable

Tools

Microsoft Office

Outlook calendar

Job description

Brown University Health seeks a registered nurse to manage utilization review, case management, and discharge planning within a hospital setting. You will ensure appropriate levels of care, obtain third-party authorizations, and educate care teams on Medicare and regulatory guidelines.

Responsibilities include applying InterQual criteria, addressing level-of-care discrepancies, and supporting expedited appeals when needed. Strong collaboration with physicians and care coordination is essential.