Manager - Utilization Review & Denials Management

Job Type: Regular

Time Type: Full time

Work Shift: Day (United States of America)

FLSA Status: Exempt

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:

• Directs staff performance regarding UR and the analysis, resolution, monitoring & reporting of clinical denials.
• Maintains current knowledge of payer contract changes as they pertain to level of care determination and the appeal/denial process.
• Oversees utilization review workflow processes to ensure timely response to denials.
• Maintains a database to track level of care determinations and status of completion.  
• Reviews and determines appropriate strategy in response to reimbursement denials.
• Responsible for appeals and follow up on clinical denials escalated through a work queue, providing appropriate response supported by clinical information.
• Provides oversight of the appeals process and direction regarding appeals and claim disputes.
• Analyzes data and identifies trends/root causes of denials for discussion with the internal team, physician advisor and the Utilization Review Committee as appropriate.
• Participate regularly in meetings with stakeholders, including hospitalists, ED physicians, etc., to provide education and prevention strategies.
• Avails self to ongoing education/training to stay current with emerging industry trends.
• Performs ongoing audits, to monitor UR and appeal/denial process and develops process improvement plans for identified deficiencies.
• Facilitates peer-to-peer communication in support of submitted claims.
• Participates on the Utilization Review Committee
• Adheres to HIPAA policies and procedures.

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 required; Bachelor’s degree in nursing, health care administration or related field preferred or commensurate experience and Case Management Certification required
• Minimum of 3 years of progressive experience in utilization management and appeal/denial management.
• Holds a strong working knowledge of InterQual Level of Care Criteria.
• Understands payer contractual guidelines for all third party and government payers.
• Holds a strong working knowledge of UR and Appeal/Denial Policies and Procedures.
• Excellent oral and written communication skills.
• Analytic and problem solving aptitude.
• Strong organizational skills & ability to prioritize and work within deadlines.
• Proficiency in all MS Office Suite applications.

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