Manager - Utilization Review & Denials Management

Beth Israel Deaconess Hospital-Plymouth; Plymouth; On-site; GBP 45,000 - 65,000; Full time

Job summary

Beth Israel Deaconess Hospital-Plymouth seeks a Utilization Review & Denials Management Manager. This full-time role oversees clinical denials management and ensures effective utilization review processes. Candidates should have current RN Licensure and case management certification, supported by strong analytical and communication skills. The position supports the hospital’s mission to provide high-quality healthcare services to the community.

Qualifications

• Minimum of 3 years of experience in utilization management.
• Strong knowledge of InterQual Level of Care Criteria.
• Understanding of payer contractual guidelines.

Responsibilities

• Direct staff performance regarding utilization review and denials management.
• Maintain knowledge of payer contract changes related to level of care.
• Analyze data to identify trends and root causes of denials.

Skills

Analytical abilities

Communication skills

Problem-solving

Organizational skills

Education

Current MA RN Licensure

Bachelor's degree in nursing or healthcare administration

Case Management Certification

Tools

MS Office Suite

Job description

Be among the first 25 applicants

Utilization Review & Denials Management Manager - Full Time

At Beth Israel Deaconess Hospital–Plymouth, our patients always come first. We are proud to be a trusted healthcare provider, offering personalized, high-quality care to the South Shore of Massachusetts. As a member of Beth Israel Lahey Health, BID-Plymouth provides comprehensive healthcare services to over 250,000 residents in Plymouth and Barnstable counties.

Role Responsibilities:

• Direct staff performance regarding utilization review (UR) and analysis, resolution, monitoring & reporting of clinical denials.
• Maintain current knowledge of payer contract changes related to level of care determination and the appeal/denial process.
• Oversee utilization review workflow processes to ensure timely responses to denials.
• Maintain a database to track level of care determinations and completion status.
• Review and determine appropriate strategies in response to reimbursement denials.
• Handle appeals and follow up on escalated clinical denials, supporting responses with clinical information.
• Provide oversight of the appeals process and guide regarding appeals and claim disputes.
• Analyze data to identify trends and root causes of denials for discussion with the internal team, physician advisors, and the Utilization Review Committee.
• Participate in meetings with stakeholders, including hospitalists and ED physicians, to provide education and prevention strategies.
• Engage in ongoing education to stay current with industry trends.
• Perform audits to monitor the UR and denial process, developing improvement plans for deficiencies.
• Facilitate peer-to-peer communication to support submitted claims.
• Participate on the Utilization Review Committee.
• Adhere to HIPAA policies and procedures.

Education/Experience Requirements:

• Current MA RN Licensure required; Bachelor’s degree in nursing, healthcare administration, or related field preferred, or equivalent experience.
• Case Management Certification required.
• Minimum of 3 years of experience in utilization management and appeal/denial management.
• Strong knowledge of InterQual Level of Care Criteria.
• Understanding of payer contractual guidelines for third-party and government payers.
• Knowledge of UR and Appeal/Denial Policies and Procedures.
• Excellent communication skills, analytical and problem-solving abilities.
• Strong organizational skills with the ability to prioritize and meet deadlines.
• Proficiency in MS Office Suite.

Beth Israel Lahey Health requires all staff to be vaccinated against influenza and COVID-19 as a condition of employment.

Seniority level

• Mid-Senior level

Employment type

• Full-time

Job function

• Accounting/Auditing and Finance

Industries

• Hospitals and Health Care