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Job Type:

Regular

Scheduled Hours:

40

Work Shift:

Day (United States of America)

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:

1, Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.

2. Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity.

3. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.

4. Works collaboratively with RN Case Managers to expedite patient discharge.

5. 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.

6. 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.

7. Assists in the orientation and precepting of professional staff and colleagues as assigned.

8. Participates in analyzing, updating, and modifying procedures and processes to continually improve utilization review operations.

9. Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications, establishing personal networks; participating in professional societies.

10. 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.

11. Reviews data of specific to utilization management functions and reports as requested.

12. 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.

FLSA Status:

Non-Exempt

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) and COVID-19 as a condition of employment. Learn more about this requirement.

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Equal Opportunity Employer/Veterans/Disabled