Utilization Management Nurse Leader

Beth Israel Lahey Health; Winchester (MA); On-site; USD 166,000 - 198,000; Full time

Job summary

Beth Israel Lahey Health is seeking an Utilization Management Specialist at Winchester Hospital. This RN-led role focuses on medical necessity surveillance, concurrent reviews, and discharge planning to ensure high-quality, cost-effective patient care.

You will collaborate with physicians, nursing, and case management teams to improve documentation, coding and reimbursement, while participating in system-level initiatives and education.

Qualifications

• RN with at least five (5) years of inpatient case management and utilization review experience.
• Current license to practice professional nursing in MA.
• Certification in Case Management within one year of hire.

Responsibilities

• Perform medical necessity surveillance, concurrent clinical reviews, and patient status oversight for reimbursement.
• Educate physicians and staff on clinical documentation and coding improvement.
• Act as Co-Chair of the Utilization Review Committee and coordinate with interdisciplinary teams.
• Manage denials, appeals, resubmissions, and audits; monitor daily census and discharge planning.
• Conduct ongoing communications with patients, families and care teams to optimize plan of care.

Skills

English communication

Computer skills

InterQual criteria

Education

Bachelors of Science in Nursing

Master’s Degree in Nursing or relevant field

Tools

InterQual criteria

Job description

Beth Israel Lahey Health is seeking an Utilization Management Specialist at Winchester Hospital. This RN-led role focuses on medical necessity surveillance, concurrent reviews, and discharge planning to ensure high-quality, cost-effective patient care.

You will collaborate with physicians, nursing, and case management teams to improve documentation, coding and reimbursement, while participating in system-level initiatives and education.