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**Job 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.

Manages the Utilization Management (UM) team, maintaining effective and efficient processes for determining appropriate patient admission status based on regulatory and reimbursement requirements of various commercial and government payers. Manages UM department in the context of other Revenue Cycle functions such as Denials & Appeals, Patient Access, Authorization Management & review, HIM, Coding & Billing. Close collaboration with the Physician Advisors, Collaborates and helps facilitate the Utilization Review Committee. Continuously monitors processes for opportunities for improvement within an interdisciplinary team and integrated Revenue Cycle effort.

Job Description:

**Essential Duties & Responsibilities** _including but not limited to:_

+ Ensures that Utilization Review nurses are consistently recommending the appropriate admission status and provides education as needed.

+ Interacts with physicians to manage high risk patients most likely to benefit from Utilization Review intervention.

+ Serves as a resource person for the Utilization Review staff and others to ensure consistent and accurate patient status determinations for appropriate claim submission.

+ Collaborates with all member of the multidisciplinary team to ensure that all patients are reviewed appropriately and the correct admission status is applied.

+ Manages the performance of all Utilization Review staff, coaching as needed and administering corrective action when appropriate.

+ Manages the performance of all UM staff, completes and monitors audits, facilitates corrective action as needed.

+ Completes annual colleague performance evaluations for all Utilization Review staff.

+ Conducts new employee interviews and selects new employees.

+ Identifies, develops and provides orientation, training, and competency development for appropriate staff on an ongoing basis.

+ Assigns and reviews staff schedules and workflows and works closely with other administrative and clinical areas under the direction of the Executive Director and the VP of Revenue Cycle/Chief Revenue Officer as part of an integrated Revenue Cycle model.

+ Ensures the Utilization Review department maintains documented, up-to-date policies and procedures and that key processes have valid outcome measures that are monitored for compliance and reported to a variety of audiences.

+ Performs a variety of concurrent and retrospective Utilization Review-related activities, ensuring that appropriate data is tracked, evaluated, and reported.

+ Monitors the effectiveness/outcomes of the Utilization Review program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.

+ Leads and/or actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff.

+ Assists the Executive Director in evaluating systems and processes in close collaboration with other revenue cycle and clinical areas.

+ Assists leadership in managing vendor relationships, IT setup and reports, data analysis, compliance reviews as needed.

+ Continuously monitors regulatory requirements for Utilization Management.

+ Attends Mandatory Education programs required by the organization.

+ Keeps current on both department and organizational activities by reviewing various communications and literature that include staff meeting minutes, newsletters, staff assemblies, etc.

+ Attends work related educational programs as required.

+ Maintains necessary continuing education requirements for licensing, certification and enhancements.

+ Maintains own education records.

+ Organizational Requirements:

+ Maintains strict adherence to the LHMC and BILH Confidentiality Policy.

+ Incorporates **LHMC Guiding Principles** , Mission Statement and Goals into daily activities.

+ Complies with all LHMC Policies. Complies with behavioral expectations of the department and LHMC Clinic.

+ Maintains courteous and effective interactions with colleagues and patients.

+ Demonstrates an understanding of the job description, performance expectations, and competency assessment.

+ Demonstrates a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.

+ Participates in departmental and/or interdepartmental quality improvement activities.

+ Participates in and successfully completes Mandatory Education.

+ Performs all other duties as needed or directed to meet the needs of the department.

Minimum Qualifications:

**Education:** Bachelor’s Degree, Master’s Degree preferred

**Licensure, Certification, Registration:** Current license as a Registered Nurse

**Skills, Knowledge & Abilities** :

+ Current and accurate knowledge of commercial and government payers and Joint Commission regulations/guidelines/criteria related to Utilization Review.

+ Well-developed knowledge and skills in medical necessity, and patient status determination.

+ Effective verbal communication, problem solving and conflict resolution skills.

+ Basic knowledge of Quality Improvement techniques.

+ Demonstrated ability to organize and work independently

+ Demonstrated ability to communicate effectively with medical and hospital staffs.

+ Proven knowledge of Revenue Cycle functions

Experience:

A minimum of three years of medical/surgical nursing care experience, including experience in a leadership role. Two years of case management or utilization management experience desirable.

Key Relationships:

Position Purpose/Activities

Executive Director HIM, Coding & UR: Receives direction regarding priorities, assignment, coordination and outcome.

Clinical Leaders: Receives direction and training from

Case Managers: Collaborates on complicated or high risk patients admitted to the Clinic

Attending Physicians: Coordinates appropriate documentation

Medical Director for /Managed Care, Physician Advisors

Works collaboratively managing the process of Utilization Review throughout the system

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 (https://www.bilh.org/newsroom/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) 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