Utilization Nurse

Beth Israel Deaconess Hospital Plymouth, Inc.; United States; On-site; USD 51,000 - 113,000; Part time

Job summary

Beth Israel Deaconess Hospital Plymouth, Inc. is seeking a Per Diem RN to perform utilization review and admission decisions using Interqual, while working with the UR team and physicians to optimize care and reimbursement.

Applicants must hold MA RN licensure and typically possess a Bachelor’s Degree in Nursing or higher; at least three years of hospital experience and familiarity with payer policies are required. Strong negotiation and independent work skills are essential.

Qualifications

• Current MA RN licensure
• Bachelor’s Degree in Nursing or advanced healthcare degree preferred
• Three years recent hospital clinical experience
• Experience with utilization management in last 3 years
• Knowledge of Interqual; Allscripts preferred
• Strong interpersonal and negotiation skills
• Understanding of government and insurer reimbursement policies
• Ability to work independently

Responsibilities

• Reviews admission data to determine level of care using Interqual.
• Integrates clinical and billing knowledge to review denials and appeals.
• Conducts concurrent reviews to assess continued need and reimbursement potential.
• Collaborates with multidisciplinary team to improve denial management and appeals.
• Liaises with UR Manager/physician advisor on cases not meeting guidelines.
• Acts as liaison between physicians and payers for peer-to-peer calls.
• Collects and compiles data as required.

Skills

Interqual criteria knowledge

Negotiation skills

Communication skills

Problem solving

Education

MA RN licensure

Bachelor’s Degree in Nursing or healthcare advanced degree preferred

Tools

Allscripts

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.

Per Diem Job Description: Beth Israel Deaconess Hospital-Plymouth recognizes Integrity, Respect, Trust, Teamwork and Excellence as the Core Values of our organization. It is the philosophy of BID-Plymouth to follow the LEAN methodology in order to provide the full continuum of health care services and the best quality patient centered care.

Duties/Responsibilities:

• Reviews admission data to establish the appropriate level of care using Interqual criteria.
• Integrates clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the hospitalized patient.
• Conducts concurrent reviews to determine the continued need for acute care setting, appropriateness and timeliness of treatments/procedures and to optimize the potential for reimbursement.
• Collaborates with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process.
• Collaborates with UR Manager and/or physician advisor regarding cases that do not meet established guidelines for admission or continued stay.
• Acts as a liaison between physicians and payers, coordinating peer-to-peer phone calls.
• Collects and compiles data as required.

Education/Experience Required:

Current MA RN licensure Bachelor’s Degree in Nursing or advanced degree in healthcare preferred. Three years recent, broad clinical experience in the hospital setting Experience with utilization management within the last 3 years required An understanding of the severity of an array illnesses, intensity of service, and care coordination needs Ability to identify appropriateness of patients admission and level of care needs (inpatient & observation) utilizing Interqual criteria Knowledge of Interqual required; Allscripts preferred Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with patients, physicians, colleagues and insurance companies Knowledge of government and insurance company reimbursement policies in regards to admission criteria, treatment and length of stay Ability to work independently.

Registration/Certification:

Current MA RN licensure

Physical/Environmental Requirements

This job requires frequent bending, carrying, pulling, pushing, reaching, standing, stooping, walking and lifting over 10 lbs. There will be occasional need for climbing stairs, lifting in excess of 50 – 100 lbs and sitting. Constant use of hearing, sight and speech. Frequent use of smell and touch. Frequent keyboard and telephone use. Constant concentration and problem solving.

Pay Range:

Pay Range: $37.14 - $82.22 This position is covered by a collective bargaining agreement. The 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. The pay range for this position is established and governed by the terms of the applicable collective bargaining agreement. Employees hired into this position will receive compensation consistent with the terms of the applicable collective bargaining agreement.

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

At Beth Israel Lahey Health, we are driving the change in health care that Massachusetts wants and needs. Our culture promotes continuous learning, growth, innovation and a sense of belonging. We make it a priority to offer comprehensive compensation and benefits and help you achieve a healthy and balanced life. While you're busy caring for and supporting our patients, we take care of you.