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Utilization Review Nurse

Burlington, Massachusetts

Organization Facility: Lahey Hospital and Medical Center Category: Utilization Management Job ID: JR33195 Date posted: 10/09/2023
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When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Type:


Scheduled Hours:


Work Shift:

Day (United States of America)

Lahey Hospital and Medical Center is now offering up to a $3,500 in signing bonuses for our Utilization Review positions.

Important Details:
• Signing Bonuses are paid out in three payments. You will receive your first payment (one third of the total amount) upon completion of the first 30 days of employment. You will receive the second payment upon completion of six (6) months and the third payment (final of the total amount) owe upon completion of one year following your start date. The bonus payments will be paid on the next regular pay day following the date on which you become eligible for the bonus. All payments are subject to applicable taxes.

To be eligible:

• Signing Bonus is determined on a full-time status of 40 hours. Hours less than 40 hours will be prorated. Per Diem roles are not eligible.

• Current and former BILH candidates - restrictions apply. Employees within the BILH system are not eligible for the bonus or if you have been employed by a BILH entity within the last 12-months.

• If you leave Lahey Hospital & Medical Center before your first anniversary you will pay back the signing bonus.
• Please note, signing bonuses are subject to change based on the organization's hiring needs and will be determined by Talent Acquisition on an ongoing basis. BILH/LHMC Talent Acquisition reserves the right to change signing bonus eligible jobs and amounts at any time.

Job Description:

Job Description:

In conjunction with the admitting/attending physician, the Utilization Review RN assists in determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. Partners with the health care team to ensure reimbursement of hospital admissions is based on medical necessity and documentation is sufficient to support the level of care being billed. Conducts concurrent reviews as directed in the hospital’s Utilization Review Plan and review of medical records to ensure criteria for admission and continued stay are met and documented.  Along with other health care team members, monitors the use of hospital resources and identifies delays.

Essential Functions and Responsibilities:

Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.
Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.
Works collaboratively with RN Case Managers to expedite patient discharge On-site in Burlington.
Maintains current knowledge of hospital utilization review processes and participates in the resolution of retrospective reimbursement issues, including appeals, third-party payer certification, and denied cases.
Monitors effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, supporting the evaluation of the data, reporting results to various audiences, and implementing process improvement projects as needed.
Assists in the orientation and precepting of professional staff and colleagues as assigned.
Participates in analyzing, updating, and modifying procedures and processes to continually improve utilization review operations.
Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications, establishing personal networks; participating in professional societies.
Complies with federal, state, and local legal and certification requirements by studying existing and new legislation, anticipating future legislation; enforcing adherence to requirements; advising management on needed actions.  
Reviews data of specific to utilization management functions and reports as requested.
Performs other related duties as required and directed.



 Licensure as a Registered Nurse (RN), Massachusetts
Three years of recent clinical or utilization management experience

Bachelor’s degree in nursing or related healthcare fields.
Competence in standardized medical necessity criteria
Three years of recent case management or utilization management experience
ACM, CCM, or CMAC Certification
Knowledge, Skills, and Abilities:

Demonstrates expertise in the utilization management principles, methods, and tools and incorporates them into the daily operations of the organization.
Understands, interprets and explains, and uses data for utilization management activities.
Applies the principles and methods necessary to perform utilization management functions.
Competency in applying the principles, methods, materials, and equipment necessary in providing utilization management services.
Demonstrates clinical expertise to effectively facilitate the evaluation of the level of care required. Develops and maintain strong collaborative working relationships with physicians, nursing colleagues, and other clinical professionals.
Provide and receive feedback in a positive and constructive manner.
Ability to understand, interpret, and explain data for utilization management functions.
Demonstrates highly developed written, verbal, and presentation skills.
Possesses knowledge of care delivery systems across the continuum of care, including trends and issues in care reimbursement. Possesses mid to high-level proficiency in navigating the Electronic Medical Record and applications related to utilization management.
Compliance with the Code of Ethics and Guide for Professional Conduct.

FLSA Status:


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

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Why join Beth Israel Lahey Health?

If you’re looking for a career where you can make a difference and explore your potential, Beth Israel Lahey Health is the place you belong. Our system includes a network of hospitals, physician practices, outpatient centers, and other healthcare facilities and we offer a broad range of careers in direct patient care, environmental services, registration, finance and many other fields. We are focused on providing compassionate and personalized healthcare with a strong reputation for clinical excellence and research and offer diverse opportunities for career growth and development. Conveniently, we have many locations in communities across Eastern Massachusetts and Southern New Hampshire.

At Beth Israel Lahey Health, we see you for all that you are – your experience and your dreams. Explore our open opportunities and find out why so many have already chosen to join our team.

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