Utilization Nurse

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

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.

It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be 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:

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.

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