Utilization Management Specialist II

🔥 6 hours ago

🇺🇸 United States – Remote

💵 $67.5k - $86.1k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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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

• Independently perform complex prospective, retrospective, and concurrent utilization management reviews • Process authorization requests for inpatient admissions, outpatient procedures, homecare services, and durable medical equipment • Generate required correspondence, including denial letters, based on medical necessity and administrative review processes • Maintain productivity and turnaround-time requirements • Ensure 100% correct letters and less than 2% error rate • Ensure templates comply with Federal, State, and regulatory requirements • Identify and refer members for care management and quality issues • Recommend process improvements and document departmental processes • Establish safe discharge planning needs and coordinate care with Health Partners, Care Managers, and Discharge Planners • Interface with physician reviewers to optimize written communication to members and referring providers • Meet third-party payer standards and regulatory/accrediting compliance requirements • Assist the Director with PI plan reporting, including appropriateness of admissions and continued-stay reviews • Participate in interdepartmental meetings to troubleshoot and resolve utilization management issues • Serve as an educational and communications resource for administration, department heads, physicians, and other groups • Keep the department manager informed of problems • Provide guidance and oversight support to non-clinical staff, including training and education of Specialist I • Act as a primary point of contact for the Utilization Management team and guide difficult reviews and processes

🎯 Requirements

• Bachelor of Science in Nursing or Master's Degree in Social Work, Counseling, or related field • 3+ years of work experience in a related job discipline • Current, unrestricted Registered Nurse (RN), Social Work, or Clinical Counselor Licensure in state(s) of practice • Ability to independently perform complex prospective, retrospective, and concurrent utilization reviews • Knowledge of medical necessity and administrative review processes • Knowledge of Federal, State, regulatory, third-party payer, and accrediting requirements • Ability to meet productivity, turnaround-time, letter accuracy, and error-rate standards • Ability to provide guidance, training, and education to non-clinical staff • Professional education relevant to utilization management and discharge planning

🏖️ Benefits

• Additional pay may apply, including shift, on-call, or weekend differentials • Benefits may apply • Regular employee status • Full-time schedule with 40 weekly hours • Support for responsible use of artificial intelligence and workplace innovation