When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Description:

Are you a case management/utilization review professional passionate about improving care delivery and patient outcomes? Beth Israel Deaconess Hospital-Plymouth is expanding its Care Transitions Department and seeking an experienced Manager of Utilization Review & Denials Management and Utilization Review Nurses to join our dedicated team. As a key part of our hospital’s commitment to quality, safety, and system efficiency, the Care Transitions team plays a vital role in ensuring seamless, patient-centered care.

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RN – Utilization Review

This role is ideal for nurses with strong documentation review skills and a deep understanding of reimbursement systems. You will manage concurrent reviews, appeal clinical denials, and support accurate level-of-care determinations.

Key Functions:

•             Conduct concurrent and retrospective reviews for level of care and continued stay

•             Lead appeals of clinical denials and collaborate with physician advisors

•             Coordinate peer-to-peer reviews between providers and insurers

•             Collect data and support denial prevention strategies

•             Integrate clinical and reimbursement knowledge for optimal outcomes

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RN Case Manager – Emergency Department UR & Discharge Planning

This position focuses on real-time discharge coordination and level-of-care review. You'll collaborate closely with physicians, nurses, patients, and community partners to ensure appropriate transitions of care from the Emergency Department and inpatient units.

Key Functions:

• Perform admission reviews and assign level of care using InterQual criteria
• Develop and manage individualized discharge plans and acts as a liaison between ED and post-acute providers
• Ensure compliance with Medicare, Code 44, and reimbursement regulations
• Address social determinants and high-risk cases in partnership with Social Work
• Advocate for safe, patient-centered discharges with strong documentation

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Requirements for Both Roles:

• Current RN license in Massachusetts
• Minimum 3 years recent acute care experience
• Case management or utilization review experience within the last 3 years
• Proficiency in InterQual required
• CCM, ACM, or other case management certification preferred or in progress

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Manager – Utilization Review & Denials Management

This role is ideal for a Manager with strong clinical knowledge, leadership skills, and a passion for innovation in Utilization Review & Denials Management who wants to make a tangible impact on both patient outcomes and organizational performance.

Key Functions:

• Oversee daily operations and directs staff performance regarding Utilization Review and the analysis, resolution, monitoring, and reporting of clinical denials
• Maintains a database to track level of care determinations and status of completion
• Consistently analyzes data and identifies trends/root causes of denials in order to strategically develop process improvement plans for identified deficiencies
• Participate on the UR Committee and adheres to HIPAA policies and procedures
• Participate regularly in meetings with stakeholders, including hospitalists, ED physicians, etc., to provide education and prevention strategies.

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) as a condition of employment.

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