RN Utilization Analyst: Drive Documentation & Care

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

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.