Utilization Review RN: Optimize Care & Reimbursement

Beth Israel Lahey Health, Inc.; Northern (KY); Hybrid; USD 52,000 - 135,000; Full time

Job summary

Beth Israel Deaconess Medical Center is seeking a Utilization Review Registered Nurse to support admission decisions and ensure medical necessity documentation aligns with payer requirements.

The RN will perform concurrent and retrospective reviews, collaborate with physicians and Case Managers, and help optimize hospital reimbursement while maintaining compliance with federal, state, and local regulations. This role requires MA RN licensure and 3 years of relevant experience.

Qualifications

• RN license in Massachusetts is required.
• Three years of recent clinical or utilization management experience.
• Bachelor’s degree in nursing or related healthcare field preferred.
• ACM/CCM/CMAC certification preferred.

Responsibilities

• Perform concurrent and retrospective utilization management reviews.
• Collaborate with physicians to determine inpatient vs. outpatient setting based on medical necessity.
• Obtain additional clinical documentation to optimize reimbursement.
• Assist RN Case Managers to expedite patient discharge.
• Maintain knowledge of utilization review processes and assist with addressing reimbursement issues.
• Monitor effectiveness of the utilization management program and report results.
• Participate in updating procedures to improve operations.
• Attend educator workshops and engage in professional development.
• Ensure compliance with federal, state, and local regulations.

Skills

RN License (MA)

Utilization Management

Data interpretation

Collaborative skills

Education

Bachelor’s degree in nursing (preferred)

Tools

EMR systems

Job description

Beth Israel Deaconess Medical Center is seeking a Utilization Review Registered Nurse to support admission decisions and ensure medical necessity documentation aligns with payer requirements.

The RN will perform concurrent and retrospective reviews, collaborate with physicians and Case Managers, and help optimize hospital reimbursement while maintaining compliance with federal, state, and local regulations. This role requires MA RN licensure and 3 years of relevant experience.