Join Beth Israel Deaconess Hospital-Plymouth as a Utilization Nurse, where you'll apply your clinical expertise to ensure the appropriate level of care for patients. Collaborate with a dedicated team to enhance patient care quality while navigating complex billing processes.
Key Responsibilities
Reviews admission data to establish the appropriate level of care using Interqual criteria
Integrates clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials
Conducts concurrent reviews for continued need for acute care
Collaborates with multidisciplinary teams to improve denial management and appeals process
Acts as a liaison between physicians and payers
Required Qualifications
Current MA RN licensure
Three years recent, broad clinical experience in the hospital setting
Experience with utilization management within the last 3 years
Ability to identify appropriateness of patients' admission and level of care needs using Interqual criteria
Knowledge of Interqual
Strong interpersonal and negotiation skills
Knowledge of government and insurance company reimbursement policies
Ability to work independently
Preferred Qualifications
Bachelor’s Degree in Nursing or advanced degree in healthcare