RN - Utilization Management & Clinical Appeals Lead

Rhode Island Hospital; Rhode Island; On-site; USD 98,000 - 195,000; Full time

Job summary

Brown University Health seeks a nursing leader to direct utilization management, including preauthorization and payor liaison staff. You will supervise, mentor, and shape the UM program while aligning with Brown's patient-centered mission in Rhode Island.

Requirements include an RI RN license, a bachelor’s in nursing, and strong knowledge of utilization review criteria; master’s degree and case-management certification are preferred.

Qualifications

• Must hold RI RN license and current nursing license.
• Bachelor's degree in nursing is required; Master's preferred.
• Understanding of Nurse Practice Act and case management certification appreciated.

Responsibilities

• Lead UM nurses, payor liaisons, and preauthorization staff including orientation, education, and competency assessment.
• Participate in interviewing and staff selection; direct activities and evaluate staff to achieve goals.
• Collaborate to develop measurements for staff competency and orientation.
• Serve as a resource to UM staff; develop departmental policies and strategic plans.
• Identify institutional needs with director and medical director; set priorities.
• Develop and adhere to budgets; ensure staffing and resources to support UM standards.
• Optimize resources to meet goals; provide on-call support for UM nurses on weekends/holidays.

Skills

Leadership

Communication

Utilization review knowledge

Nursing licensure

Education

Bachelor's degree in nursing

Master's degree in nursing or health discipline

Understanding of Nurse Practice Act

Case management certification (preferred)

Job description

Brown University Health seeks a nursing leader to direct utilization management, including preauthorization and payor liaison staff. You will supervise, mentor, and shape the UM program while aligning with Brown's patient-centered mission in Rhode Island.

Requirements include an RI RN license, a bachelor’s in nursing, and strong knowledge of utilization review criteria; master’s degree and case-management certification are preferred.