- 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
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utilization reviewer
Found in: Careerbuilder One Red US C2 - 2 days ago
Partners Healthcare System Belmont, MA, USA, United StatesResponsible for obtaining initial insurance authorizations for all applicable coverage and for appropriate level of clinical care. Must demonstrate McLean values of integrity, compassion and respect, diversity and teamwork, excellence and innovation consistently in their work act ...
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utilization review nurse
Found in: Careerbuilder One Red US C2 - 4 days ago
Beth Israel Lahey Health Burlington, MA , USA, United StatesWhen 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: · Evening (United States of America) · Lahey Hospital and Medical Center is now offering up to a $3,500 in ...
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utilization review nurse
Found in: Careerbuilder One Red US C2 - 4 days ago
Beth Israel Lahey Health Burlington, MA , USA, United StatesWhen 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: · 8 · Work Shift: · Day (United States of America) · Lahey Hospital and Medical Center is now offering up to a $3,500 in signi ...
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utilization review nurse
Found in: Careerbuilder One Red US C2 - 4 days ago
Milford Regional Medical Center Milford, MA , USA, United StatesPer diem, 8a-4;30P as needed weekends + occ/ holidays About Us Milford Regional Medical Center is a full-service, community and regional teaching hospital located in Milford, Mass. and serves patients from more than 20 towns in Central Massachusetts. The 149-bed medical center is ...
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utilization review care manager rn
Found in: MyJobHelper US C2 - 4 days ago
Partners Healthcare System Newton, MA , USA, United StatesThe Utilization Review RN Care Manager (CM) focuses on ensuring accurate and timely utilization review of the hospital medical surgical and maternal child health inpatient population. Utilization Review includes the process of applying accepted utilization standards and or nation ...
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physician advisor of utilization review and case management
Found in: MyJobHelper US C2 - 4 days ago
Beth Israel Lahey Health Burlington, MA , USA, United StatesWhen 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: · 20 · Work Shift: · Day (United States of America) · Position Summary: Reporting directly to the Chief Medical Officer (CMO), ...
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Associate Medical Director, Utilization Management Reviewer
Found in: beBee S2 US - 4 weeks ago
Cohere Health Greater Boston Area, United States Full timeCompany 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 ...
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Lab Coordinator
Found in: SonicJobs Direct Apply US - 1 day ago
Actalent Boston, United States Full timeDescription: · Working under the direction of the Administrative Manager, the Surgical Pathology Coordinator is responsible for the registration and insurance verification of consult cases received by the Pathology Service; the accessioning of specimens according to approved prot ...
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Lab Assistant
Found in: SonicJobs Direct Apply US - 4 days ago
Actalent Boston, United States Full timeDescription: · Working under the direction of the Administrative Manager, the Surgical Pathology Coordinator is responsible for the registration and insurance verification of consult cases received by the Pathology Service; the accessioning of specimens according to approved prot ...
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Validation Maintenance Manager
Found in: SonicJobs Direct Apply US - 4 days ago
Takeda Pharmaceutical Boston, United States Full timeBy clicking the "Apply" button, I understand that my employment application process with Takeda will commence and that the information I provide in my application will be processed in line with Takeda'sPrivacy Notice and Terms of Use. I further attest that all information I subm ...
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Scientist, Process Chemistry
Found in: SonicJobs Direct Apply US - 4 days ago
Takeda Pharmaceutical Boston, United States Full timeBy clicking the "Apply" button, I understand that my employment application process with Takeda will commence and that the information I provide in my application will be processed in line with Takeda'sPrivacy Notice and Terms of Use. I further attest that all information I subm ...
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Registered Nurse
Found in: SonicJobs Direct Apply US - 13 hours ago
Mount Auburn Hospital Cambridge, United States Full timeWhen you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives. · Job Type: · RegularScheduled Hours: · 24Work Shift: · Rotating (United States of America)Job Description · Job Description · Primary Responsibilities · 1. The emerge ...
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Associate Engineering Fellow, Process Engineering
Found in: SonicJobs Direct Apply US - 2 days ago
Takeda Pharmaceutical Cambridge, United States Full timeBy clicking the "Apply" button, I understand that my employment application process with Takeda will commence and that the information I provide in my application will be processed in line with Takeda'sPrivacy Notice and Terms of Use. I further attest that all information I subm ...
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Associate Director, Process Engineering
Found in: SonicJobs Direct Apply US - 4 days ago
Takeda Pharmaceutical Cambridge, United States Full timeBy clicking the "Apply" button, I understand that my employment application process with Takeda will commence and that the information I provide in my application will be processed in line with Takeda'sPrivacy Notice and Terms of Use. I further attest that all information I subm ...
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Medical Assistant, 40hr
Found in: SonicJobs Direct Apply US - 4 days ago
Winchester Hospital Woburn, United States Full timeWhen you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives. · Job Type: · RegularScheduled Hours: · 40Work Shift: · Day (United States of America)Contributes to Winchester Physician Associates' mission by assisting in the deliv ...
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Program Director, Danvers Treatment Center
Found in: SonicJobs Direct Apply US - 4 days ago
Beth Israel Lahey Health Behavioral Services Danvers, United StatesWhen you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives. · Job Type: · RegularScheduled Hours: · 40Work Shift: · Day (United States of America)Job Description: · Sign on bonus up to $3000 (pro-rated for part time) · Under th ...
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Quality Control Scientist
Found in: SonicJobs Direct Apply US - 4 days ago
Actalent Billerica, United States Full timeExciting opportunity to join a leading therapeutic company in the Billerica, MA area. Apply today for immediate consideration. · Description: · Support QC laboratory efforts and write protocols and SOPs for HPLC, GC, UVVIS, Etc. · Support qualification of HPLCs and chemistry equ ...
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Quality Control Technician
Found in: SonicJobs Direct Apply US - 4 days ago
Actalent North Billerica, United States Full timeDescription: · Support QC laboratory efforts and write protocols and SOPs for HPLC, GC, UVVIS, Etc. · Support qualification of HPLCs and chemistry equipment · Utilize empower software and LIMS · Perform tech transfer activities · Review and change documents for change controls, C ...
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Quality Control Technician
Found in: SonicJobs Direct Apply US - 4 days ago
Actalent North Billerica, United States Full timeGreat opportunity to get your foot in the door with one of the top diagnostics and therapeutics companies in the Billerica, MA area · If interested, please reach out directly to Lindsee Allienello at lallienello @ · Description: · Support QC laboratory efforts and write protoc ...
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Quality Control Technician
Found in: SonicJobs Direct Apply US - 4 days ago
Actalent North Billerica, United States Full timeGreat opportunity to get your foot in the door with one of the top diagnostics and therapeutics companies in the Billerica, MA area · If interested, please reach out directly to Alison at ) · Description: · Support QC laboratory efforts and write protocols and SOPs for HPLC, GC, ...
Utilization Review RN - Boston, United States - Beth Israel Deaconess Medical Center
Description
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:
RegularScheduled Hours:
40Work 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
Preferred:
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