Registered Nurse – Utilization Review
Veterans in Healthcare – Plymouth, MA. Part‑time, 32 hours per week. Day shifts (7am‑3:30pm flexible). $36.41–$74.59 per hour (collective bargaining agreement).
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.
Duties and 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 care provided to hospitalized patients.
Conducts concurrent reviews to determine the continued need for an acute care setting, appropriateness and timeliness of treatments/procedures and to optimize reimbursement.
Collaborates with the multidisciplinary team to assess and improve 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 liaison between physicians and payers, coordinating peer‑to‑peer phone calls.
Collects and compiles data as required.
Education and 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.
Understanding of severity of illnesses, intensity of service and care coordination needs.
Ability to identify appropriateness of patient admission and level of care needs (inpatient & observation) using Interqual criteria.
Knowledge of Interqual required; Allscripts preferred.
Strong interpersonal and negotiation skills with a positive, pleasant, professional and cooperative demeanor with patients, physicians, colleagues and insurance companies.
Knowledge of government and insurance company reimbursement policies regarding admission criteria, treatment and length of stay.
Ability to work independently.
Registration/Certification
Current MA RN licensure.
Equal Opportunity Statement
Equal Opportunity Employer/Veterans/Disabled. Beth Israel Lahey Health—includes all entities—maintains policies of equal employment opportunity and non‑discrimination. If accommodations are needed, contact kerith.dickinson@bilh.org .