Utilization Review Analyst - Registered Nurse (Per Diem)
Apply for the Utilization Review Analyst - Registered Nurse (Per Diem) role at Beth Israel Lahey Health .
When you join the growing BILH team, you’re not just taking a job, you’re making a difference in people’s lives. This position is per diem. The minimum commitment/availability is 16 hours per month, though the team is ideally looking for someone who can work upwards of 5 shifts per month. We offer 8‑hour shifts, with shifts available days and weekends. This position is on‑site at Lahey Hospital and Medical Center.
The Utilization Analyst works with physicians, payers, and the inpatient case management team to validate the medical necessity of the hospital care. Using the concepts of utilization review, clinical documentation improvement, and revenue integrity, these specialized case managers analyze medical documentation to ensure that proper reimbursement will be achieved in coordination with the intensity of medical care provided.
Essential Duties & Responsibilities
Completes initial reviews of patient records within 24–48 hours of admission: evaluate documentation to evaluate medical necessity of the hospital care.
Conducts follow‑up reviews of patients daily in accordance with payer requirements.
Speaks with Attending physicians regarding status determinations and/or supportive documentation.
Educates physicians and key healthcare providers regarding the need for accurate and complete documentation in the medical record in correlation with the correct level of care.
Collaborates with case managers, nursing staff, coding team, the physicians and finance on relevant issues.
Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
Reviews external (i.e. PEPPER) and internal data (i.e. outliers) to trend, track and educate to improve outcomes.
Assists with preparation and presentation of utilization review monitoring/trending reports for review with physicians and hospital leadership.
Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.
Instructs staff on best practices to ensure reimbursement based on medical care provided.
Maintains and reports clinical documentation improvement results in a clear and concise manner to the medical, clinical, and management staff.
Applies diplomacy and professionalism when interacting with physicians and clinical staff; especially when addressing missing or conflicting medical record information.
Experience: Must have at least 5 years inpatient UR/CM experience. Knowledge of payment methodologies, federal and state regulations, organization and communication skills required.
Pay Range: $38.11 - $98.23 per hour. The pay range listed is the base hourly wage 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, and location. Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with law.
Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.