Be among the first 25 applicants
Utilization Review & Denials Management Manager - Full Time
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.
Role Responsibilities:
* Direct staff performance regarding utilization review (UR) and analysis, resolution, monitoring & reporting of clinical denials.
* Maintain current knowledge of payer contract changes related to level of care determination and the appeal/denial process.
* Oversee utilization review workflow processes to ensure timely responses to denials.
* Maintain a database to track level of care determinations and completion status.
* Review and determine appropriate strategies in response to reimbursement denials.
* Handle appeals and follow up on escalated clinical denials, supporting responses with clinical information.
* Provide oversight of the appeals process and guide regarding appeals and claim disputes.
* Analyze data to identify trends and root causes of denials for discussion with the internal team, physician advisors, and the Utilization Review Committee.
* Participate in meetings with stakeholders, including hospitalists and ED physicians, to provide education and prevention strategies.
* Engage in ongoing education to stay current with industry trends.
* Perform audits to monitor the UR and denial process, developing improvement plans for deficiencies.
* Facilitate peer-to-peer communication to support submitted claims.
* Participate on the Utilization Review Committee.
* Adhere to HIPAA policies and procedures.
Education/Experience Requirements:
* Current MA RN Licensure required; Bachelor’s degree in nursing, healthcare administration, or related field preferred, or equivalent experience.
* Case Management Certification required.
* Minimum of 3 years of experience in utilization management and appeal/denial management.
* Strong knowledge of InterQual Level of Care Criteria.
* Understanding of payer contractual guidelines for third-party and government payers.
* Knowledge of UR and Appeal/Denial Policies and Procedures.
* Excellent communication skills, analytical and problem-solving abilities.
* Strong organizational skills with the ability to prioritize and meet deadlines.
* Proficiency in MS Office Suite.
Beth Israel Lahey Health requires all staff to be vaccinated against influenza and COVID-19 as a condition of employment.
Seniority level
* Mid-Senior level
Employment type
* Full-time
Job function
* Accounting/Auditing and Finance
Industries
* Hospitals and Health Care
#J-18808-Ljbffr