Registered Nurse – Utilization Review (Per Diem)

Beth-Israel-Lahey-Health; Burlington (MA); On-site; USD 52,000 - 135,000; Full time

Job summary

Beth Israel Lahey Health in Massachusetts is seeking an Utilization Analyst who will validate medical necessity of hospital care, collaborate with physicians, case management and coding teams, and drive improvements in documentation and reimbursement processes.

The role requires RN licensure with 5+ years of inpatient utilization review/case management experience, and knowledge of payer requirements. A strong focus on accurate documentation and reimbursement outcomes is essential.

Qualifications

• RN license required.
• Bachelor's degree desirable.
• 5+ years inpatient UR/CM experience.
• Knowledge of payment methodologies and regulations.

Responsibilities

• Complete initial reviews of patient records within 24–48 hours to assess medical necessity.
• Conduct daily follow-up reviews per payer requirements.
• Discuss status determinations with Attending physicians and request supportive documentation.
• Educate physicians and providers on documentation needed for appropriate level of care.
• Collaborate with case managers, nursing, coding, physicians and finance on issues.
• Analyze trends in data to identify improvement opportunities for patient populations.
• Review external (PEPPER) and internal data to trend and educate for better outcomes.
• Prepare and present utilization monitoring/trending reports for leadership.
• Educate patient care team on documentation and reimbursement issues identified through reviews.
• Instruct staff on best practices to ensure reimbursement based on care provided.
• Maintain and report outcomes of clinical documentation improvement to staff.

Skills

Inpatient UR/CM

Education

RN license

RN with CDIP/CCM/ACM desirable

Job description

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

Job Description:

Essential Duties & Responsibilities including but not limited to:

• 1. Completes initial reviews of patient records within 24–48 hours of admission: evaluate documentation to evaluate medical necessity of the hospital care.
• 2. Conducts follow-up reviews of patients daily in accordance with payer requirements.
• 3. Speaks with Attending physicians regarding status determinations and/or supportive documentation.
• 4. 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..
• 5. Collaborates with case managers, nursing staff , coding team , the physicians and finance on relevant issues,
• 6. Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
• 7. Reviews external (i.e. PEPPER) and internal data (i.e. outliers) to trend, track and educate to improve outcomes.
• 8. Assists with preparation and presentation of utilization review monitoring/trending reports for review with physicians and hospital leadership.
• 9. 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.
• 10. Instructs staff on best practices to ensure reimbursement based on medical care provided.
• 11. Maintains and reports clinical documentation improvement results in a clear and concise manner to the medical, clinical, and management staff.
• 12. Applies diplomacy and professionalism when interacting with physicians and clinical staff; especially when addressing missing or conflicting medical record informationMinimum 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 experienceKnowledge of payment methodologies, federal and state regulations, organization and communication skills required.

Pay Range:

$38.11 - $98.23The pay range listed for this position is the base hourly wage range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geographyof work location, job responsibilities, or other applicable factors permissible by law. Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with the law.

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) as a condition of employment.

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