Utilization Nurse
Company: Beth Israel Deaconess Hospital Plymouth
Location: Plymouth
Posted on: July 10, 2025
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Job Description:
Job Type:Regular Time Type:Full time Work Shift:Day (United
States of America) FLSA Status:Non-Exempt When you join the growing
BILH team, you're not just taking a job, you’re making a difference
in people’s lives. full time 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. 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 moreabout 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 OpportunityEmployer/Veterans/Disabled
Keywords: Beth Israel Deaconess Hospital Plymouth, Arlington , Utilization Nurse, Healthcare , Plymouth, Massachusetts
