EastProvidenceRecruiter Since 2001
the smart solution for East Providence jobs

Utilization Management Nurse

Company: Neighborhood Health Plan of RI
Location: East Providence
Posted on: November 16, 2020

Job Description:

The Utilization Management Nurse works collaboratively with the health care team to ensure proper utilization of medical services, procedures and care settings for individual members by assessing member needs and identifying solutions that promote quality and cost-effective care in the transition of care from the acute setting. The Utilization Management Nurse determines medical appropriateness for inpatient and outpatient services by evaluating medical information and applying established national criteria benefit determination, medical guidelines and compliance with state mandated regulations based on InterQual and other organizational tools. This includes concurrent reviews of inpatient/outpatient services, sub-acute care and prior-authorization reviews.

This role is on the Medicaid team as an Outpatient Reviewer.

Assess members needs, performing pre-certification, concurrent and retrospective review of out-patient and in-patient services, including onsite at various contracted hospitals and/or telephonic using established criteria, plan benefit guidelines, and clinical judgment to determine appropriateness of medical services, procedures and care setting

Refers and discusses complex case or cases that do not meet established criteria and guidelines with the Physician Advisor

Collaborates with staff, physicians, care/service coordinators, and medical director to coordinate and provide the level of care necessity to meet the members health need

Ensures that all company policies relative to privacy and confidentiality are followed and that any information either obtained or disclosed is done in confidence.

Evaluates requests for outpatient services such as home care, therapies and DME and makes authorization decisions based on medical necessity, benefit coverage, and the ongoing needs of the individual member

Reviews requests for conditional benefits and utilizes established company clinical guidelines to determine medical necessity. Presents to Physician Advisor for authorization decision, as necessary

Recognizes Continuity of Care and Coordination of Benefits utilization requirements

Supports the referrals to case management of complex cases through use of the case management software system

Collaborates with peers internally and externally to continually ensure members health care needs are being met in accordance with the benefit plans and through identification of agreed upon alternative services.

Documents cost savings that may result from medical review process (i.e. bed downgrades, change to observation status, alternative setting, etc.)

Meets department and regulatory standards for accuracy, proficiency and documentation in order to communicate decisions and plan of care in an appropriate and timely manner, and to ensure appropriate reimbursement in the Claims adjudication system

Follows and maintains compliance with regulatory agency requirements and participate in continues quality improvement activities

Attends all required trainings and management-identified meetings in person. In certain circumstances, the employee may be allowed to conference in, at the discretion of the management team

Other duties as assigned

Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents


Graduate from an Accredited School of Nursing

Active and unrestricted Registered Nurse License in state of Rhode Island (Consideration will be given to individuals without current RI license. Must provide documentation confirming RI RN application within 24 hours of offer)

Three (3) years of experience in acute care, hospital setting or long term care admission assessments

Previous experience performing utilization management for Medicare Advantage, Managed Care, Medicaid, Duals and Commercial Lines of Business

Previous experience with Discharge Planning, Medical Review guidelines and/or CMS requirements

Demonstrated knowledge in medical practices, utilization management processes/standards, insurance benefit structures, managed care and clinical documentation

Detailed knowledge of clinical guidelines or medical-necessity decisions relating to inpatient, sub-acute/skilled care, outpatient care, hospice care, or home health care

Advanced level experience utilizing Health Care Management/Authorization Software, or Electronic Health Record (EHR)

Ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families

Strong communication (verbal and written) organizational, multitasking and teamwork skills

High level of professionalism and integrity with adherence to all confidentiality requirements

Ability to work weekends

Ability to provide rotational coverage as needed


Bachelor of Science in Nursing (BSN) from an accredited school of nursing

Three (3) years of experience in utilization management

Utilization Review or Case Management Certification

Previous experience in behavioral health and/or long term care environment

Bilingual (English/Spanish)

Core Company-Wide Competencies:

Communicate Effectively

Respect Others & Value Diversity

Analyze Issues & Solve Problems

Drive for Customer Success

Manage Performance, Productivity & Results

Develop Flexibility & Achieve Change

Job Specific Competencies:

Build Relationships & Cultivate Networks

Influence & Negotiate

Attend to Detail & Improve Quality

Exercise Sound Judgement & Decision Making

Flexible Work Arrangement:

Yes, with prior approval of supervisor

Telecommuting Arrangement:

Yes with prior approval of supervisor, within a schedule that meets the needs of the company and allows for meeting continued performance expectations

Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.

Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org

by Jobble

Keywords: Neighborhood Health Plan of RI, East Providence , Utilization Management Nurse, Other , East Providence, Rhode Island

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category

Other Other Jobs

Process Engineering Manager (Design Group)
Description: About Us: Design Group operates from more than 45 offices in the United States and India, providing engineering, consulting and technical services for the world s leading companies in the food and (more...)
Company: Barry Wehmiller Design Group
Location: Concord
Posted on: 11/25/2020

Pallet Shop / Saw Mill Worker
Description: This position will be working in the Saw Mill.-- Job consists of stacking pallets, using hand tools, working
Company: PeopleReady
Location: Concord
Posted on: 11/25/2020

Amazon Warehouse Team Member Full Time $16-19/hr - Immediate Openings
Description: Location: Taunton, MA Job opportunities vary by location. We update postings daily with open positions. Hourly pay rate: 16.00 - 19.00/hr Immediate openings available now. Amazon remains open (more...)
Company: Amazon Workforce Staffing
Location: East Providence
Posted on: 11/25/2020

Class A CDL Car Haul Truck Drivers
Description: Job Description Now Hiring CDL-A Drivers for Dedicated Runs - Car Haul Car Haulers -
Company: Hogan Transportation
Location: East Providence
Posted on: 11/25/2020

Customer Service Representative - Work from Home - USA
Description: Join our TTEC work from home customerservice representative team if you reside in 45 out of 50 states. We cannotaccept applications for residents of CA, CO, HI, IL or NY or outside of the UnitedStates. (more...)
Company: TTEC
Location: Concord
Posted on: 11/25/2020

Entry Level Automotive Technician/Customer Service Advisor
Description: Accelerate Your Potential Geared for the Driven Interested in a rewarding career with great pay, outstanding benefits and the opportunity to grow Henley Enterprises Inc, the largest franchisee of Valvoline (more...)
Company: Valvoline Instant Oil Change
Location: Concord
Posted on: 11/25/2020

Postmates Part Time Delivery Driver (Same Day Activation) - In Nashua, NH
Description: Postmates has the largest on-demand fleet in the U.S. with 200,000 Postmates, and an equally extensive network of merchants. While some companies try to build a warehouse outside of a city and funnel (more...)
Company: Postmates
Location: Concord
Posted on: 11/25/2020

CDL A Company Truck Driver OTR Dedicated NE Routes
Description: Join the WEL Family and Drive For Greater Things Give us a call at 844 513-1932 Northeast Dedicated Driver Home Weekly - 81,900 GUARANTEED Pay - 401k Match WEL Companies has been family owned (more...)
Company: WEL Companies
Location: East Providence
Posted on: 11/25/2020

Amazon Warehouse Assistant - Immediate Openings!
Description: Seasonal Part-time Warehouse Team Member - Hourly pay rate: Earn 16.00 - 21.00/hr , plus benefits The base pay for this role is 16.00/hr Limited-time Opportunity. Earn 2/hr extra for select (more...)
Company: Amazon
Location: Woonsocket
Posted on: 11/25/2020

Truck Driver CDL A - $7,500 Sign On Bonus!
Description: CDL A Truck Drivers Needed 7,500 Driver Sign On Bonus We offer 100 paid health care, great home time and more Call 866-576-0048 to speak with a recruiter Join
Company: New Penn
Location: Woonsocket
Posted on: 11/25/2020

Log In or Create An Account

Get the latest Rhode Island jobs by following @recnetRI on Twitter!

East Providence RSS job feeds