RN Utilization Review Specialist – Care Management (Hiring Immediately) Position Available In Hillsborough, New Hampshire

Job Description:

RN Utilization Review This position has onsite requirements

Who We Are:

– Elliot Health System’s Care Coordination Department,located in Manchester, NH, plays a vital role in ensuring seamless,patient-centered care across the healthcare continuum. Our team isdedicated to care management, discharge planning, and patientadvocacy, working closely with providers, social workers, andcommunity resources to enhance patient outcomes. By developingindividualized care plans, facilitating smooth transitions betweencare settings, and offering proactive support, we help patientsnavigate complex healthcare needs while improving overall access tohigh-quality, coordinated care. About the

Job:

Under the direction of the Director of Care Coordination, theUtilization Review RN (UR RN) is responsible for ensuring theeffective and efficient use of hospital services in alignment withthe hospital’s utilization review plan.

What You’ll Do:

Complete admission reviews to determine the appropriate level ofcare. Document continued stay reviews to assess the necessity ofinpatient care, procedures, and estimated length of stay. Communicate and collaborate with payer care managers to preventdenials by ensuring timely clinical reviews. Address potential denials proactively, working with physicians andpayer representatives to minimize retrospective denials. Screen all patients upon admission or the next business day todetermine appropriate level of care using medical necessity tools,Medicare Inpatient Only List, and payer requirements. Monitor observation status patients to ensure appropriateutilization, and collaborate with admitting physicians ifdocumentation does not support the current level of care. Perform concurrent reviews to justify extended stays, working withattending physicians to ensure accurate documentation of medicalnecessity. Refer cases that do not meet admission or continued stay guidelinesto the Utilization Review Physician Advisor after discussions withattending physicians.

Who You Are:

Graduate of an accredited nursing program (Bachelor’s degree inNursing required for nurses hired after May 2015 or commitment toobtain within a specified timeframe). Minimum of three (3) years of experience in hospital casemanagement or utilization management. Active New Hampshire or Compact State RN license required. CCM or ACM certification preferred.

Why You’ll Love Us:

Health, dental, prescription, and vision coverage for full-time ∂-time employees Short-term, long-term disability, life & pet insurance Tuition reimbursement 403(b) Retirement savings plans Continuous earned time accrual #LAM