RN Utilization Review Leader

Elliot Health System; Manchester (NH); On-site; USD 110,000 - 150,000; Full time

Benefits offered by this job

Health, dental, vision coverage

Disability and Life Insurance

Tuition reimbursement

403(b) retirement savings plan

Paid time off

Job summary

Elliot Health System in Manchester, NH seeks an RN Manager Utilization Review to lead the UR function, drive care coordination integrations, and ensure compliant, high-quality payer communications. The role partners with physician leadership, revenue cycle, and quality teams to optimize resource use.

Responsibilities include staff leadership, complex case reviews, and ongoing policy adherence, with a focus on improving denial prevention and patient outcomes within regulatory guidelines.

Qualifications

• Graduate of an accredited nursing program; RN license required in NH or Compact state.
• Managerial experience preferred with knowledge of Utilization Review and InterQual.
• Experience in denials management, case management, and utilization metrics.

Responsibilities

• Lead UR staff and operations to ensure accurate, timely level-of-care determinations and clinical submissions.
• Provide second-level review and escalation support for complex cases, denials, and appeals.
• Ensure consistent application of InterQual criteria and best practices in documentation.
• Direct denial prevention and mitigation strategies with trend tracking and action plans.
• Monitor utilization performance indicators including denial rates, appeal outcomes, and LOS impact.
• Collaborate with finance and revenue cycle to understand payer trends and guide financial health strategies.
• Ensure CMS Conditions of Participation, payer contracts, accreditation standards, and hospital policies are followed.
• Participate in Utilization Management Oversight committees and regulatory reviews.
• Build relationships with physicians, nursing leadership, case management, quality and payers.
• Lead data-driven quality improvement initiatives related to utilization management and care coordination outcomes.
• Identify process inefficiencies and champion innovative solutions to improve patient flow and payer communication.
• Promote education, competency development, and evidence-based practice.
• Demonstrate the organization’s mission and values in daily work.

Skills

Leadership

People management

Analytical skills

Process improvement

Clinical decision-making

Education

Bachelor's degree in Nursing

Master's degree preferred

Tools

InterQual

Job description

Elliot Health System in Manchester, NH seeks an RN Manager Utilization Review to lead the UR function, drive care coordination integrations, and ensure compliant, high-quality payer communications. The role partners with physician leadership, revenue cycle, and quality teams to optimize resource use.

Responsibilities include staff leadership, complex case reviews, and ongoing policy adherence, with a focus on improving denial prevention and patient outcomes within regulatory guidelines.