Utilization Mgt Specialist - Per Diem

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Location: Winchester, MA
Job ID: 167654-1A
Date Posted: Sep 13, 2022
Category: Nursing

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Job Description

Welcome To

Welcome to Winchester Hospital, part of Beth Israel Lahey Health. Winchester Hospital was the first hospital in Massachusetts to earn Magnet recognition, the American Nurses Association’s highest honor for nursing excellence, three times. It has since received the recognition a fourth time. As the northwest suburban Boston area’s leading provider of comprehensive health care services, the 229-bed facility provides care in general, bariatric and vascular surgery, orthopedics, pediatrics, cardiology, pulmonary medicine, oncology, gastroenterology, rehabilitation, radiation oncology, pain management, obstetrics/gynecology and a Level IIB Special Care Nursery.


About the Job

JOB SUMMARY: Contributes to the Hospital’s mission by supporting proper classification and a safe plan of care. This professional licensed position will have an impact on finance and growth by classifying patients’ status appropriately and supporting a care plan to ensure the delivery of high quality, safe patient care while maintaining an expected length of stay within budget. This role functions as a utilization expert, collaborating interdepartmentally to educate and improve processes to appropriate classify patient status, which ultimately improves reimbursement. The Utilization Management Specialist will impact the patient experience and quality of care by daily rounding and working with the patient/family and provider to establish the best plan of care for discharge.


This position works in tandem with the case management department and may be called upon at any time to function in the role of case manager/care coordinator to accommodate departmental needs.




Hired Prior to 10/1/13:  Graduate of a state approved and/or accredited RN program.

Hired On or After 10/1/13:  Bachelors’ degree in Nursing (BSN) or obtain BSN within 5 years of hire



BSN upon hire




·        At least five (5) years of clinical experience as a Registered Nurse

·        Experience educating and/or formal presenting.



·        Previous Case Management or Utilization Review experience


Other Skills/Knowledge


·        For safety and quality reasons, must be able to read, write and communicate effectively in English with patients, visitors, vendors, and fellow members of the hospital team.

·        Computer skills


·        InterQual Criteria




·        Current license to practice professional nursing from MA Board of Registration


·        Professional certification



·        BLS Required



Neonate, Infant, Children, Adolescent, Adult, and Geriatric



Professional Commitment Requirements:  Keep abreast of developments in the field and/or licensure through continuing education, participation in professional organizations or a combination of both.

On-call:  Contingent on the needs of the department.

Schedule requirements:  Contingent on the needs of the department.  Holiday rotation and weekend coverage as dictated by the needs of the department.

Travel requirements:   Local travel may be needed for training, education, and participation in system level meetings.



·        Reports to the Manager of Case Management

·        Not responsible for supervising the work of others


While the list below describes the primary functions of this job, all employees at Winchester Hospital need to recognize that an essential element of their job is the ability to respond to unanticipated and/or changing situations.  This may result in assuming responsibilities or tasks which are not on this list.


The candidate will perform medical necessity surveillance, concurrent clinical reviews,  patient status oversight and management, and coordination with financial team to ensure proper reimbursement.


The Utilization Management Specialist promotes the documentation of medical necessity and resource consumption during an inpatient hospitalization. 


Provides concurrent and retrospective queries as supported by medical record documentation to improve the accuracy, integrity and quality of patient data, and improve the quality of the physician documentation within the body of the medical record.  The candidate collaborates with all members of the case management department, unit managers, physicians and physician groups, staff nurses, coding staff and the multidisciplinary team. This role requires the ability to educate and present in both formal and informal venues for the purposes of hospital-wide compliance and continual performance improvement.


Medical Necessity/Utilization Reviewer:

· Completes initial reviews of patient records upon admission and within 24–48 hours for medical necessity surveillance: Reviews all observation and Medicare one day stays for proper leveling, observation vs inpatient.

·Manages all workqueues and follow up related to denials, appeals, resubmissions, audits, variances, and those created as a result of evolving work flows.

· Conducts follow-up reviews of patients every 2–3 days to ensure all elements of medical necessity and 2 MN Rule are documented 

Initiates the provision of beneficiary notices to patients or families.

·Queries physicians regarding missing, unclear, or conflicting medical record documentation by requesting and obtaining additional documentation within the medical record when needed.

Interacts with team and providers to ensure correct level of care, status and accurate documentation to support patient stay.  Works close with Physician Advisor and CDI staff.

Proactively works with payer reviews-  Performs concurrent reviews-.  Reviews tests, procedures ordered for appropriateness/consultant delays. Coordinates second level peer to peer (physician) clinical reviews

Educates physicians and key healthcare providers in both formal and informal settings regarding clinical documentation improvement and the need for accurate and complete documentation in the medical record.

·Collaborates with case managers, nursing staff, coding team and inter-professional staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.


Care Coordinator RN role:

This position works in tandem with the case management department and may be called upon at any time to function in the role of case manager/care coordinator to accommodate departmental needs.

·        Utilizes the case management process to provide quality and safe patient care by identifying the specific needs of the patient and developing the plan of care for discharge with the patient.

·        Establishes a therapeutic relationship with the patient, the patient's family and significant others by involving them in each step of the care coordination process and accommodates factors that may influence the plan of discharge.

·        Collaborates with the multi-disciplinary healthcare team regarding the patient’s plan of care to promote the best possible outcomes and patient/family experience upon discharge.

·        Addresses the patient’s physical, emotional, cultural, and spiritual needs.

·        Performs all required documentation accurately, legibly and timely.

·        Appropriately follows the chain of command and adheres to hospital policies and procedures.

·        Greets patients.  Rounds on patients daily to educate and inform them of their plan of care.

·        To assess the daily case management workflow and optimize the team’s efficiency, gathers census information, reviews admissions, reconciles admissions, transfers and discharges against census and conducts hand-offs regarding patients when appropriate.

·        Reviews discharges to verify the required insurance approvals have been received.

·        Collaborates with the patient, patient’s family, insurance companies and the multi-disciplinary team to determine and coordinate the patient’s next level of care.

·        Patient care rounds with multi-disciplinary team to review the plan of care.

·        Documents and develops plan of care in preparation for discharge.

·        Collaborates with other healthcare facilities and external vendors to assist patients and patient families in setting up services to transition safely upon discharge to the next level of care.

·        Contacts insurance companies to obtain authorizations for hospital stays and levels of care upon discharge.

Physical And Mental Requirements/ Conditions

·        It is anticipated that employee may have contact with potentially hazardous chemicals while performing their job duties.

·        It is anticipated that the employee may have contact with blood, bodily fluids or other potentially infectious materials while performing their job duties.



Per diem

About Us

Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve.  Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health.  Beth Israel Lahey Health Performance Network is a unified joint contracting and population health management organization, jointly governed by participating physicians and hospitals.

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.