Utilization Review RN: Optimize Care & Reimbursement

Beth Israel Lahey Health; Boston (MA); On-site; USD 53,000 - 136,000; Full time

Job summary

Beth Israel Lahey Health is seeking an experienced Utilization Review RN to partner with physicians and the care team. You will determine admission status, review records for medical necessity, and help maximize appropriate hospital reimbursement through strong documentation and collaboration.

The role focuses on concurrent and retrospective reviews, data reporting, and process improvements while maintaining compliance with relevant regulations.

Qualifications

• Licensure as a Registered Nurse (RN), Massachusetts.
• Three years of recent clinical or utilization management experience.
• 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.

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.

Skills

Utilization management

Clinical documentation

Data interpretation

Interprofessional collaboration

EMR navigation

Communication

Education

RN license, MA

Bachelor’s degree in nursing or related healthcare fields

ACM/CCM/CMAC Certification

Tools

EMR systems

Job description

Beth Israel Lahey Health is seeking an experienced Utilization Review RN to partner with physicians and the care team. You will determine admission status, review records for medical necessity, and help maximize appropriate hospital reimbursement through strong documentation and collaboration.

The role focuses on concurrent and retrospective reviews, data reporting, and process improvements while maintaining compliance with relevant regulations.