Learn more about working at Beth Israel Deaconess Hospital Plymouth
Manager - Utilization Review & Denials Management
Plymouth, Massachusetts
Organization Facility: Beth Israel Deaconess Hospital Plymouth Category: Billing, Collections, & Patient Financial Services Job ID: JR69241 Date posted: 01/27/2025Job 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.
Full TimeJob Description:
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 as a Utilization Review & Denials Management Manager, you will:
- 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.
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.
Ready to make an impact on patient nutrition and wellness?
Apply today and become part of our dedicated Clinical Nutrition Team!
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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