Utilization Review RN

3 weeks ago

Boston, United States Beth Israel Deaconess Medical Center Full time

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

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.

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

  • Associate Medical Director, Utilization Management Reviewer

    4 weeks ago

    Greater Boston Area, United States Cohere Health Full time

    Company Overview:Cohere Health is illuminating healthcare for patients, their doctors, and all those who are important in a patient's healthcare experience, both in and out of the doctor's office. Founded in August 2019, we are obsessed with eliminating wasteful friction that patients and doctors experience in areas that have nothing to do with health and...

  • MA - Family Nurse Practitioner - Lawrence

    2 days ago

    Boston, United States RN-Staff Full time

    Established in 1980, the Greater Lawrence Family Health Center, Inc. (GLFHC) is a multi-site, mission-driven, non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to a culturally diverse population throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family...

  • Utilization Management Supervisor

    2 days ago

    Boston, United States Commonwealth Care Alliance Full time

    Why This Role is Important to Us Supervisor & The Team Leader reports to the UM Manager. The Team Leader provides management,oversight and mentorship to team members and ensures that Team members are meeting quality and productivity standards. The Team Leader works in close collaboration with the manager and Director of the UM team. What You'll...

  • Stormwater and Utility Engineer III

    4 weeks ago

    Boston, United States HNTB Full time

    What We're Looking For At HNTB, you can create a career that is meaningful to you while building communities that matter to all of us. For more than a century, we have been delivering solutions for some of the largest, most complex infrastructure projects across the country. With our historic growth, it is an exciting time to join our team of...

  • RN - Med Surg

    1 week ago

    Boston, United States All Medical Personnel Full time

    Specialty: RN- Medical/Surgical - TravelJob Description Clinical Expertise: Collaborates with other members of the health care team to develop, implement, and evaluate an individualized written plan of care based upon a physiological, psychosocial, spiritual assessment consistent with patient/significant other's changing needs & goals, utilizing the...

  • RN Outpatient

    7 days ago

    Boston, United States INFOPRO LEARNING PRIVATE LIMITED Full time

    *Job Title:- RN Outpatient**Job Location:- Boston, MA**Job Type:- Contract/Temp.**Duration:- 13 weeks**Shift/Hours:- 08:00 - 16:30**Job Description:** Post Heart Transplant Coordinators triage all calls, pages, Patient Gateway Messages providing open communication with patients during the week.* Reviewing labs, medication orders, and collaborating with MD/NP...

  • Case Manager RN

    2 days ago

    Boston, United States Professional Staffing Group Full time

    Case Manager RN This fully remote contract position is available exclusively to candidates residing in Massachusetts. We are seeking a dedicated Case Manager RN for a fully remote contract position, offering $45 per hour. The Clinical Care Manager will be responsible for facilitating care for members and their families who may have rising health risks or...

  • RN Case Manager

    2 days ago

    Boston, United States Integrated Resources, Inc Full time

    Job Title: RN Case Manager Job Location: Boston, MA Job Duration: 2 + Months (Possibilities of Extension) Shift: 8-hour days 7:30 – 5 pm Monday - Friday; hire can move to 4x10s after the first week of orientation. Case Manager – Pediatrics Job Details: · As a Case Manager RN, responsibilities are not...

  • Registered Nurse, RN

    1 week ago

    Boston, United States Tufts Medicine Full time

    Tufts Medical Center is recognized by the ANCC Magnet Recognition Program® for excellence in nursing. Magnet® recognition is the highest and most prestigious credential a health care organization can achieve for nursing excellence and quality patient care. Magnet® recognition signals to nurses that the organization is committed to nursing. The nurses at...

  • rn/lpn

    2 days ago

    Boston, Massachusetts, United States Volunteers of America Massachusetts Full time

    : The Opportunity: Contracted Registered Nurse (RN) or Licensed Practical Nurse (LPN) a residential settingJob Type: Full-time or Part-time, On-SiteDuration: 4 Months (April- August 2024)Pay: $40- $50/hour VOAMASS is seeking a local contract nurse for a 4 month contract nursing job in Boston, Massachusetts at our various residential recovery homes. What We...

  • Case Manager RN

    1 week ago

    Boston, United States ProPivotal Staffing Full time

    Case Manager RN - $45/hr (Massachusetts)Fully remote position but candidate must be residing in Massachusetts.We are seeking a highly skilled and self-directed Registered Nurse Case Manager to join our healthcare team remotely in Massachusetts. This role offers a competitive hourly rate of $45 and the opportunity to facilitate comprehensive care for members...

  • Electric Utility Construction Manager

    1 month ago

    Boston, United States ESPO Corporation Full time

    Electric Utility Construction Manager / QC InspectorLocation: Dorchester, MADuration: 9 + month contractMust be local to the Greater Boston Area (Manager is estimating approximately 75% field work and 25% in office work)Work Hours: 8am-5pm ETWork Days: Mon-Fri.Job Description SummaryAll work done by Contractor shall be in accordance with Owner's Quality...

  • Electric Utility Construction Manager

    5 days ago

    Boston, United States ESPO Corporation Full time

    Electric Utility Construction Manager / QC InspectorLocation: Dorchester, MADuration: 9 + month contractMust be local to the Greater Boston Area (Manager is estimating approximately 75% field work and 25% in office work)Work Hours: 8am-5pm ETWork Days: Mon-Fri.Job Description SummaryAll work done by Contractor shall be in accordance with Owner's Quality...

  • RN - Flexible Shifts ($50/hr Start Immediately)

    4 weeks ago

    Boston, United States ProPivotal Remote Work Freelance Full time

    RN - Flexible Shifts ($50/hr Start Immediately) What's In It For You: - $50 per hour pay rate - You can start right away - An organization that recognizes and rewards hard work - Friendly and supportive healthcare professionals - Well-equipped and modern facility - Good work environment and culture About the Opportunity: - We are currently hiring...

  • Trach/ Vent Private Duty Nurse RN

    4 weeks ago

    Boston, United States Aveanna Healthcare Full time

    Position OverviewRegistered Nurse (RN) is responsible for providing and documenting skilled nursing care in accordance with the developed care plan and physicians orders for each individual patient while adhering to confidentiality standards and professional boundaries at all times.Essential Job Functions• Responsible for the delivery and coordination of...

  • RN Field Supervisor Home Care

    1 week ago

    Boston, United States Glades Talent Full time

    RN FIELD SUPERVISOR- JOB DESCRIPTION Promotes and restores patients’ health by developing day-to-day management and long-term planning of the patient care area.Hires, onboards, directs, mentors, develops, and schedules staff, including communicating job expectations and providing performance reviews.Collaborates with physicians and multidisciplinary...

  • RN Field Supervisor Home Care

    2 weeks ago

    Boston, Massachusetts, United States Glades Talent Full time

    RN FIELD SUPERVISOR- JOB DESCRIPTION Promotes and restores patients' health by developing day-to-day management and long-term planning of the patient care area.Hires, onboards, directs, mentors, develops, and schedules staff, including communicating job expectations and providing performance reviews.Collaborates with physicians and multidisciplinary...

  • RN Field Supervisor-

    4 weeks ago

    Boston, United States Glades Talent Full time

    Job DescriptionJob DescriptionRN FIELD SUPERVISOR- JOB DESCRIPTIONPromotes and restores patients' health by developing day-to-day management and long-term planning of the patient care area.Hires, onboards, directs, mentors, develops, and schedules staff, including communicating job expectations and providing performance reviews.Collaborates with...

  • Chronic Care RN

    4 days ago

    Boston, MA, United States TalentBurst, Inc. Full time

    Title: Chronic Care Registered Nurse (RN) 12 months or more of Recent Dialysis experience required Location: Boston MA    The Client registered nurse (RN) is responsible for the delivery of quality patient care through the nursing process of assessment, diagnosing, planning implementation and evaluation. The RN is responsible for directing and...

  • CHRONIC CARE RN

    2 weeks ago

    Boston, MA 02215, USA, United States TalentBurst, Inc. Full time

    Title: Chronic Care Registered Nurse (RN)12 months or more of Recent Dialysis experience requiredLocation: Boston MA  The Client registered nurse (RN) is responsible for the delivery of quality patient care through the nursing process of assessment, diagnosing, planning implementation and evaluation. The RN is responsible for directing and coordinating...