Strategic Payor Liaison for Utilization Review

Brown University Health; Providence (RI); On-site; USD 84,000 - 167,000; Full time

Job summary

Brown University Health, located at Rhode Island Hospital in Providence, RI, seeks an UR liaison to monitor third-party requirements and coordinate the utilization review program. You will work with care managers and physicians to ensure appropriate admission status and timely denials management.

The role requires an RN with Rhode Island licensure, 3+ years in clinical/administrative UR, and strong data reporting skills to support ongoing audits and quality improvement.

Qualifications

• Bachelor’s Degree in nursing or related health science required.
• Registered Nurse licensure in Rhode Island required.
• Three years or more of relevant recent clinical and/or administrative experience in an acute care setting; two years in utilization review.

Responsibilities

• Monitors and ensures compliance with third-party requirements related to utilization review; liaison with payers regarding patient status.
• Consults with other hospital departments and medical staff on UR issues, including pre-certification for admission or status for surgical patients.
• Coordinates UR program and educates UR care managers on InterQual criteria; provides input on goals, policies and standards.
• Manages data reporting of HINNs to UR committee; leads denial mitigation by negotiating patient status with payors.
• Prepares and maintains UR documentation, records and statistics; ensures completeness and accuracy.
• Communicates with leadership and denials management about concurrent appeals status.
• Participates in committees to develop UR policies and procedures; conducts retrospective reviews for appropriate level of care.

Skills

Utilization review

InterQual criteria

Data reporting

Education/training

Education

Bachelor’s in Nursing

Job description

Brown University Health, located at Rhode Island Hospital in Providence, RI, seeks an UR liaison to monitor third-party requirements and coordinate the utilization review program. You will work with care managers and physicians to ensure appropriate admission status and timely denials management.

The role requires an RN with Rhode Island licensure, 3+ years in clinical/administrative UR, and strong data reporting skills to support ongoing audits and quality improvement.