Utilization Care Manager: Clinical Review & Discharge

Rhode Island Hospital; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

Rhode Island Hospital is seeking an experienced Registered Nurse to lead utilization review and ensure appropriate levels of care for patients. The role involves coordinating with physicians, payers, and the care team to optimize admission decisions and discharge planning.

The incumbent will apply InterQual criteria, manage concurrent reviews, and educate staff on Medicare and payer guidelines, while delivering timely notices of non-coverage when appropriate.

Qualifications

• RN licensure in Rhode Island or compact, in-state eligibility.
• Bachelor's degree in Nursing required; Master's degree preferred.
• CPHM certification highly desirable.
• Five years of clinical experience with utilization review, case management or discharge planning preferred.

Responsibilities

• Conducts surveillance of medical necessity for patient care records.
• Applies InterQual level of care criteria to admissions within one business day.
• Reviews admissions and provides clinical information to third-party payers.
• Delivers HINN notices when inpatient care is not medically necessary.
• Coordinates with care team and payer representatives to optimize discharge planning.

Skills

Nursing knowledge

InterQual criteria

Analytical skills

Communication skills

Team collaboration

Education

Bachelor's degree in Nursing

Master's degree preferred

Tools

Microsoft Office

Job description

Rhode Island Hospital is seeking an experienced Registered Nurse to lead utilization review and ensure appropriate levels of care for patients. The role involves coordinating with physicians, payers, and the care team to optimize admission decisions and discharge planning.

The incumbent will apply InterQual criteria, manage concurrent reviews, and educate staff on Medicare and payer guidelines, while delivering timely notices of non-coverage when appropriate.