Job Description
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
Utilization Review & Denials Management Manager - Full Time
Who We Are
At Beth Israel Deaconess Hospital–Plymouth, our patients always come first. We are proud to be a trusted healthcare provider, offering personalized, high-quality care to the South Shore of Massachusetts. As a member of Beth Israel Lahey Health, BID‑Plymouth provides comprehensive healthcare services to over 250,000 residents in Plymouth and Barnstable counties. Our Nutrition Services Team consists of registered and licensed dietitians who provide expert nutritional interventions to improve patient health outcomes.
Join Our Team of Experts and Serve Your Community!
In Your Role
Direct staff performance regarding utilization review and the analysis, resolution, monitoring, and reporting of clinical denials.
Maintain current knowledge of payer contract changes as they pertain to level‑of‑care determination and the appeal/denial process.
Oversee utilization review workflow processes to ensure timely response to denials.
Maintain a database to track level‑of‑care determinations and status of completion.
Review and determine 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.
Provide oversight of the appeals process and direction regarding appeals and claim disputes.
Analyze data and identify trends/root causes of denials for discussion with the internal team, physician advisors, and the Utilization Review Committee as appropriate.
Participate regularly in meetings with stakeholders, including hospitalists and ED physicians, to provide education and prevention strategies.
Avail self to ongoing education/training to stay current with emerging industry trends.
Perform ongoing audits to monitor utilization review and appeal/denial processes and develop process‑improvement plans for identified deficiencies.
Facilitate peer‑to‑peer communication in support of submitted claims.
Participate on the Utilization Review Committee.
Adhere to HIPAA policies and procedures.
Education/Experience Required
Current MA RN licensure required; Bachelor’s degree in nursing, health care administration, or related field preferred or commensurate experience; Case Management certification required.
Minimum of 3 years of progressive experience in utilization management and appeal/denial management.
Hold a strong working knowledge of InterQual Level of Care Criteria.
Understand payer contractual guidelines for all third‑party and government payers.
Hold a strong working knowledge of utilization review and appeal/denial policies and procedures.
Excellent oral and written communication skills.
Analytical and problem‑solving aptitude.
Strong organizational skills and ability to prioritize and work within deadlines.
Proficiency in all MS Office Suite applications.
Why Join Us?
At Beth Israel Lahey Health, we prioritize the well‑being of our employees. Our Total Rewards program offers competitive compensation and comprehensive benefits to enhance your personal and professional life. Beth Israel Lahey Health requires that all staff be vaccinated against influenza as a condition of employment.
Pay Range
$31,200.00 USD – $1,040,000.00 USD.
The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, including seniority, education, training, relevant experience, certifications, geography, job responsibilities, and other applicable factors permissible by law.