Massachusetts Jobs

Job Type: Regular

Time Type: Full time

Work Shift: Day (United States of America)

FLSA Status: Exempt

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Description:

The Utilization Analyst works with physicians, the payers and inpatient case management team to validate the medical necessity of the hospital care.

Using the concepts of utilization review, clinical documentation improvement and revenue integrity, these specialized case managers analyze medical documentation to ensure that proper reimbursement will be achieved in coordination to the intensity of medical care provided.

This role specifically works with insurance appeals and denials, this role is onsite.

Essential Duties & Responsibilities including but not limited to :

-Completes initial reviews of patient records within 24–48 hours of admission: evaluate documentation to evaluate medical necessity of the hospital care.

-Conducts follow-up reviews of patients daily in accordance with payer requirements.

-Speaks with Attending physicians regarding status determinations and/or supportive documentation.

-Educates physicians and key healthcare providers regarding the need for accurate and complete documentation in the medical record in correlation with the correct level of care..

-Collaborates with case managers, nursing staff , coding team , the physicians and finance on relevant issues,

-Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.

-Reviews external (i.e. PEPPER) and internal data (i.e. outliers) to trend, track and educate to improve outcomes.

-Assists with preparation and presentation of utilization review monitoring/trending reports for review with physicians and hospital leadership.

-Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.

-Instructs staff on best practices to ensure reimbursement based on medical care provided.

-Maintains and reports clinical documentation improvement results in a clear and concise manner to the medical, clinical, and management staff.

-Applies diplomacy and professionalism when interacting with physicians and clinical staff; especially when addressing missing or conflicting medical record information

Organizational Requirements:

-Maintain strict adherence to the Lahey Hospital and Medical Center Confidentiality policy.

-Incorporate Lahey Hospital and Medical Center Standards of Behavior and Guiding Principles into daily activities

-Comply with all Lahey Hospital and Medical Center Policies.

-Comply with behavioral expectations of the department and Lahey Hospital and Medical Center.

-Maintain courteous and effective interactions with colleagues and patients.

-Demonstrate an understanding of the job description, performance expectations, and competency assessment.

-Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.

-Participate in departmental and/or interdepartmental quality improvement activities.

-Participate in and successfully completes Mandatory Education.

-Perform all other duties as needed or directed to meet the needs of the department.

Minimum Qualifications:

Education :

RN, Bachelor’s degree desirable.

Licensure, Certification & Registration :

RN; RN with CDIP, CCM, ACM highly desirable.

Experience :

Must have at least 5 years inpatient UR/CM experience

Knowledge of payment methodologies, federal and state regulations, organization and communication skills required.

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more (https://www.bilh.org/newsroom/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled