Senior Utilization Management Specialist, RN

🔥 4 hours ago

🏈 Ohio – Remote

🏈 Ohio – Remote

💵 $74.3k - $94.7k / year

⏰ Full Time

🟠 Senior

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Cincinnati Children's

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1883

🏥 Healthcare

🤝 Non-profit

📚 Education

Healthcare • Non-profit • Education

Cincinnati Children's is a leading children's hospital dedicated to providing exceptional healthcare services for infants, children, and adolescents. The hospital offers a wide range of resources, including urgent care, specialty care, and clinical trials. With a commitment to education, research, and community support, Cincinnati Children's aims to deliver the best outcomes and ensure the comfort of young patients and their families.

📋 Description

• Ensure Utilization Management Specialists follow policies and processes for authorization requests • Lead the interface between the authorization processing team and Health Partners, Care Managers, and Discharge Planners • Provide oversight for non-clinical medical management staff • Identify and refer appropriate members for care management and quality issues to Quality Improvement • Oversee interrater reliability audits for Patient Care Coordinators • Ensure templates comply with Federal, State, and Regulatory requirements • Document, identify, and communicate discharge planning needs and coordination of care • Meet third-party payer standards and requirements • Monitor regulatory and accrediting compliance impacts on reimbursement • Assist the Director with reporting under the PI plan, including appropriateness of admissions and continued stay reviews and resource utilization • Participate in interdepartmental meetings to promote knowledge and resolve utilization management issues • Serve as an educational and communications resource regarding utilization management activities and processes • Keep the department manager informed of problems • Oversee audits and ensure regular staff feedback • Analyze data, formulate recommendations, and maintain utilization management reporting

🎯 Requirements

• Bachelor of Science in Nursing • 5+ years of work experience in a related job discipline • Current, unrestricted Registered Nurse (RN) Ohio licensure • Must reside within 70 miles of ZIP code 45229, Cincinnati, Ohio • Ability to oversee authorization processing, audits, utilization management reporting, and discharge planning coordination • Knowledge of Federal, State, regulatory, accrediting, and third-party payer requirements

🏖️ Benefits

• Additional pay may apply, including shift, on-call, or weekend differentials • Comprehensive job description provided upon request • Reasonable accommodations for qualified individuals with disabilities • Equal opportunity employment environment committed to dignity and respect