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Beth Israel Lahey Health · 3 days ago

Manager - Utilization Review & Denials Management

Plymouth, MA

Full-time

Onsite

Mid Level

$130K/yr - $160K/yr

3+ years exp

Beth Israel Lahey Health is a trusted healthcare provider offering personalized, high-quality care to the South Shore of Massachusetts. As a Utilization Review & Denials Management Manager, you will oversee staff performance related to clinical denials and ensure timely responses to denials while maintaining knowledge of payer contract changes.

Elder CareHealth CareHospitalPrimary and Urgent CareProfessional ServicesTraining

Responsibilities

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

Qualification

MA RN LicensureCase Management CertificationUtilization ManagementInterQual Level of CareAnalytic skillsMS Office SuiteCommunication skillsOrganizational skillsProblem solving