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Beth Israel Lahey Health REGISTERED NURSE - Utilization Review in Plymouth, Massachusetts

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

Job Type:

Regular

Scheduled Hours:

24

Work Shift:

Day (United States of America)

24 hpw; 8-hr shifts (7a-3:30p flex); rotating weekends and holidays

Job Description:

Duties/Responsibilities:

  • Reviews admission data to establish the appropriate level of care using Interqual criteria.

  • Integrates clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the hospitalized patient.

  • Conducts concurrent reviews to determine the continued need for acute care setting, appropriateness and timeliness of treatments/procedures and to optimize the potential for reimbursement.

  • Collaborates with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process.

  • Collaborates with UR Manager and/or physician advisor regarding cases that do not meet established guidelines for admission or continued stay.

  • Acts as a liaison between physicians and payers, coordinating peer-to-peer phone calls.

  • Collects and compiles data as required.

It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.

Education/Experience Required:

  • Current MA RN licensure

  • Bachelor’s Degree in Nursing or advanced degree in healthcare preferred.

  • Three years recent, broad clinical experience in the hospital setting

  • Experience with utilization management within the last 3 years required

  • An understanding of the severity of an array illnesses, intensity of service, and care coordination needs

  • Ability to identify appropriateness of patients admission and level of care needs (inpatient & observation) utilizing Interqual criteria

  • Knowledged of Interqual required; Allscripts preferred

  • Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with patients, physicians, colleagues and insurance companies

  • Knowledge of government and insurance company reimbursement policies in regards to admission criteria, treatment and length of stay

  • Ability to work independently

Registration/Certification:

  • Current MA RN licensure

FLSA Status:

Non-Exempt

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

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