RN - Utilization Review & Care Optimization

Beth Israel Deaconess Medical Center, Inc.; United States; On-site; USD 55,000 - 135,000; Full time

Job summary

Beth Israel Lahey Health seeks an RN Utilization Review professional to support admission decisions and ensure reimbursement aligns with medical necessity. You will review records, collaborate with physicians and care teams, and advocate for appropriate levels of care.

The role emphasizes data-driven reviews, documentation improvement, and coordination with discharge planning to optimize patient flow and payer adherence.

Qualifications

• RN licensure in Massachusetts.
• Three years of recent clinical or utilization management experience.
• Certification in ACM/CCM/CMAC preferred.
• Familiarity with medical necessity criteria.

Responsibilities

• Perform concurrent and retrospective utilization management reviews and data reporting.
• Collaborate with health care team to determine inpatient vs. outpatient setting based on medical necessity.
• Obtain additional clinical documentation to optimize hospital reimbursement.
• Support discharge planning with RN Case Managers to expedite patient flow.
• Maintain knowledge of utilization review processes and participate in issue resolution and appeals.

Skills

Utilization management

Clinical documentation

Data interpretation

Collaborative care

Presentation skills

Education

Bachelor’s degree in nursing or related healthcare fields

ACM/CCM/CMAC Certification

Tools

Electronic Medical Records (EMR)

Job description

Beth Israel Lahey Health seeks an RN Utilization Review professional to support admission decisions and ensure reimbursement aligns with medical necessity. You will review records, collaborate with physicians and care teams, and advocate for appropriate levels of care.

The role emphasizes data-driven reviews, documentation improvement, and coordination with discharge planning to optimize patient flow and payer adherence.