Utilization Review Registered Nurse

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

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

Position Summary:

In conjunction with the admitting/attending physician, the Utilization Review RN assists in determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. Partners with the health care team to ensure reimbursement of hospital admissions is based on medical necessity and documentation is sufficient to support the level of care being billed. Conducts concurrent reviews as directed in the hospital’s Utilization Review Plan and review of medical records to ensure criteria for admission and continued stay are met and documented. Along with other health care team members, monitors the use of hospital resources and identifies delays.

Job Description:

Essential Functions and Responsibilities:

• Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.
• Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity.
• Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.
• Works collaboratively with RN Case Managers to expedite patient discharge.
• Maintains current knowledge of hospital utilization review processes and participates in the resolution of retrospective reimbursement issues, including appeals, third-party payer certification, and denied cases.
• Monitors effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, supporting the evaluation of the data, reporting results to various audiences, and implementing process improvement projects as needed.
• Assists in the orientation and precepting of professional staff and colleagues as assigned.
• Participates in analyzing, updating, and modifying procedures and processes to continually improve utilization review operations.
• Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications, establishing personal networks; participating in professional societies.
• Complies with federal, state, and local legal and certification requirements by studying existing and new legislation, anticipating future legislation; enforcing adherence to requirements; advising management on needed actions.
• Reviews data of specific to utilization management functions and reports as requested.
• Performs other related duties as required and directed.

Qualifications:

• Required Licensure as a Registered Nurse (RN), Massachusetts
• Three years of recent clinical or utilization management experience
• Preferred: Bachelor’s degree in nursing or related healthcare fields.
• Competence in standardized medical necessity criteria
• Three years of recent case management or utilization management experience
• ACM, CCM, or CMAC Certification

Knowledge, Skills, and Abilities:

• Demonstrates expertise in the utilization management principles, methods, and tools and incorporates them into the daily operations of the organization.
• Understands, interprets and explains, and uses data for utilization management activities.
• Applies the principles and methods necessary to perform utilization management functions.
• Competency in applying the principles, methods, materials, and equipment necessary in providing utilization management services.
• Demonstrates clinical expertise to effectively facilitate the evaluation of the level of care required.
• Develops and maintain strong collaborative working relationships with physicians, nursing colleagues, and other clinical professionals.
• Provide and receive feedback in a positive and constructive manner.
• Ability to understand, interpret, and explain data for utilization management functions.
• Demonstrates highly developed written, verbal, and presentation skills.
• Possesses knowledge of care delivery systems across the continuum of care, including trends and issues in care reimbursement.
• Possesses mid to high-level proficiency in navigating the Electronic Medical Record and applications related to utilization management.
• Compliance with the Code of Ethics and Guide for Professional Conduct.

Pay Range:

$38.11 - $98.61 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. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of 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.

Other:

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:

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.