Manager - Utilization Review - Full time - Days

Location: Burlington, MA
Job ID: 171946-1A
Date Posted: Jan 21, 2022
Category: Nursing

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Job Description

Welcome To

Welcome to Lahey Hospital & Medical Center, part of Beth Israel Lahey Health. Lahey Hospital & Medical Center is a world-renowned tertiary medical center known for its innovative technology, pioneering medical treatment and leading-edge research. A teaching hospital of Tufts University School of Medicine, the hospital provides quality health care in virtually every specialty and subspecialty, from primary care to cancer diagnosis and treatment to kidney and liver transplantation. It is a national leader in a number of health care areas, including stroke, weight management and lung screenings, among many others. Lahey also helps to advance medicine through research and the education of tomorrow's health care leaders.

About the Job

Position Summary: 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.

Minimum Qualifications:

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

Licensure, Certification, Registration:  Current license as a MA 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


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.



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.