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- Tasks: Lead a team in managing clinical denials and utilization reviews to ensure quality patient care.
- Company: Join Beth Israel Deaconess Hospital–Plymouth, a trusted healthcare provider serving over 250,000 residents.
- Benefits: Enjoy a full-time role with opportunities for professional growth and ongoing education.
- Why this job: Make a real impact in healthcare while working in a supportive and dynamic environment.
- Qualifications: Must have MA RN Licensure, Case Management Certification, and 3 years of relevant experience.
- Other info: Vaccination against influenza and COVID-19 is required for all staff.
The predicted salary is between 36000 - 60000 £ per year.
At Beth Israel Deaconess Hospital–Plymouth, our patients always come first. We are proud to be a trusted healthcare provider, offering personalized, high-quality care to the South Shore of Massachusetts. As a member of Beth Israel Lahey Health, BID-Plymouth provides comprehensive healthcare services to over 250,000 residents in Plymouth and Barnstable counties.
Role Responsibilities:
- Direct staff performance regarding utilization review (UR) and analysis, resolution, monitoring & reporting of clinical denials.
- Maintain current knowledge of payer contract changes related to level of care determination and the appeal/denial process.
- Oversee utilization review workflow processes to ensure timely responses to denials.
- Maintain a database to track level of care determinations and completion status.
- Review and determine appropriate strategies in response to reimbursement denials.
- Handle appeals and follow up on escalated clinical denials, supporting responses with clinical information.
- Provide oversight of the appeals process and guide regarding appeals and claim disputes.
- Analyze data to identify trends and root causes of denials for discussion with the internal team, physician advisors, and the Utilization Review Committee.
- Participate in meetings with stakeholders, including hospitalists and ED physicians, to provide education and prevention strategies.
- Engage in ongoing education to stay current with industry trends.
- Perform audits to monitor the UR and denial process, developing improvement plans for deficiencies.
- Facilitate peer-to-peer communication to support submitted claims.
- Participate on the Utilization Review Committee.
- Adhere to HIPAA policies and procedures.
Education/Experience Requirements:
- Current MA RN Licensure required; Bachelor’s degree in nursing, healthcare administration, or related field preferred, or equivalent experience.
- Case Management Certification required.
- Minimum of 3 years of experience in utilization management and appeal/denial management.
- Strong knowledge of InterQual Level of Care Criteria.
- Understanding of payer contractual guidelines for third-party and government payers.
- Knowledge of UR and Appeal/Denial Policies and Procedures.
- Excellent communication skills, analytical and problem-solving abilities.
- Strong organizational skills with the ability to prioritize and meet deadlines.
- Proficiency in MS Office Suite.
Beth Israel Lahey Health requires all staff to be vaccinated against influenza and COVID-19 as a condition of employment.
Manager - Utilization Review & Denials Management employer: Beth Israel Deaconess Hospital-Plymouth
Contact Detail:
Beth Israel Deaconess Hospital-Plymouth Recruiting Team
StudySmarter Expert Advice 🤫
We think this is how you could land Manager - Utilization Review & Denials Management
✨Tip Number 1
Familiarise yourself with the latest trends in Utilization Review and Denials Management. Understanding current industry standards and payer contract changes will not only boost your confidence but also demonstrate your commitment to staying updated, which is crucial for this role.
✨Tip Number 2
Network with professionals in the healthcare field, especially those involved in Utilization Review. Attend relevant workshops or webinars to connect with others and gain insights that could give you an edge during interviews.
✨Tip Number 3
Prepare to discuss specific examples from your past experience where you've successfully managed denials or improved UR processes. Being able to articulate your achievements will help you stand out as a candidate who can deliver results.
✨Tip Number 4
Research Beth Israel Deaconess Hospital–Plymouth and understand their values and mission. Tailoring your conversation to align with their focus on high-quality patient care will show that you're not just looking for any job, but are genuinely interested in contributing to their team.
We think you need these skills to ace Manager - Utilization Review & Denials Management
Some tips for your application 🫡
Tailor Your CV: Make sure your CV highlights relevant experience in utilization review and denials management. Emphasise your nursing qualifications, case management certification, and any specific achievements related to the role.
Craft a Compelling Cover Letter: Write a cover letter that directly addresses the responsibilities outlined in the job description. Use specific examples from your past experience to demonstrate how you meet the requirements and can contribute to the team at Beth Israel Deaconess Hospital–Plymouth.
Highlight Relevant Skills: In your application, focus on key skills such as analytical abilities, communication skills, and knowledge of UR and appeal/denial policies. Mention your proficiency in MS Office Suite and any experience with data analysis or trend identification.
Follow Application Instructions: Carefully read the application instructions provided by Beth Israel Deaconess Hospital–Plymouth. Ensure that you submit all required documents, including your CV and cover letter, through our website to avoid any issues with your application.
How to prepare for a job interview at Beth Israel Deaconess Hospital-Plymouth
✨Know Your Stuff
Make sure you have a solid understanding of Utilization Review and Denials Management. Brush up on the latest industry trends, payer contract changes, and the appeal process. This knowledge will help you answer questions confidently and demonstrate your expertise.
✨Showcase Your Experience
Prepare to discuss your previous experience in utilization management and how you've handled denials in the past. Be ready with specific examples that highlight your problem-solving skills and your ability to analyse data to identify trends.
✨Communication is Key
Since this role involves working with various stakeholders, emphasise your communication skills. Be prepared to discuss how you've facilitated peer-to-peer communication and educated teams on prevention strategies in your previous roles.
✨Ask Insightful Questions
At the end of the interview, don’t forget to ask questions. Inquire about the current challenges the team faces in UR and denial management or how they measure success in this role. This shows your genuine interest and helps you assess if the position is the right fit for you.
