[Hiring] Utilization Nurse @TriHealth

Role Description

Join Our Team as a Utilization Nurse! This position reports to the supervisor or manager of Utilization Management. The Utilization Management (UM) Nurse is responsible for evaluation of medical necessity to ensure care is delivered at the appropriate level, and aligns with regulatory and payer requirements. The UM Nurse collaborates with physicians, care management and payers to ensure authorization of provided services. All candidates for this position should have knowledge of computer programs such as Microsoft Outlook, Microsoft Word, TEAMS, EPIC, and Voalte. Working autonomously is necessary so it is essential that time management and self-discipline be strong characteristics of candidates for this role.

Job Responsibilities

• Performs initial and concurrent reviews to determine medical necessity using evidenced based criteria.
• Validates the appropriate patient class (inpatient, observation, bedded outpatient) based on CMS regulations, payer requirements and department protocol.
• Provides initial and concurrent clinical information to payers timely based on individual payer requirements. Follows up with payers as needed to ensure authorization is obtained.
• Coordinates with interdisciplinary care team, including attending physicians, physician advisors and care management.
• Recognizes and documents delays in care; escalates as appropriate.

Qualifications

• Associate's Degree - Nursing (Required)
• New hires required to obtain BSN within 5 years of hire (Required)
• 3 - 4 years of clinical experience in nursing (Required)
• Specialty Patient Care Guidelines
• Basic computer skills
• Problem solving
• Establish effective working relationship with members of healthcare team and external customers
• Prior experience in self-directed position
• Registered Nurse Upon Hire Required
• Membership in related professional organization (Preferred)

Requirements

• Location: Remote
• Work Schedule: Full - Time (80 hours bi-weekly), Day shift

Benefits

• Comprehensive benefits package, including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement.

Working Conditions

• Bending - Rarely
• Climbing - Rarely
• Concentrating - Consistently
• Continuous Learning - Consistently
• Hearing: Conversation - Consistently
• Hearing: Other Sounds - Consistently
• Interpersonal Communication - Consistently
• Kneeling - Rarely
• Lifting <10 Lbs. - Frequently
• Lifting 50+ Lbs. - Rarely
• Lifting <50 Lbs. - Rarely
• Pulling - Rarely
• Pushing - Rarely
• Reaching - Frequently
• Reading - Consistently
• Sitting - Consistently
• Standing - Occasionally
• Stooping - Rarely
• Talking - Consistently
• Thinking/Reasoning - Consistently
• Use of Hands - Consistently
• Color Vision - Frequently
• Visual Acuity: Far - Occasionally
• Visual Acuity: Near - Frequently
• Walking - Occasionally

TriHealth SERVE Standards and ALWAYS Behaviors

• Serve: ALWAYS… Welcome everyone by making eye contact, greeting with a smile, and saying "hello". Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist. Refrain from using cell phones for personal reasons in public spaces or patient care areas.
• Excel: ALWAYS… Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met. Offer patients and guests priority when waiting (lines, elevators). Work on improving quality, safety, and service.
• Respect: ALWAYS… Respect cultural and spiritual differences and honor individual preferences. Respect everyone’s opinion and contribution, regardless of title/role. Speak positively about my team members and other departments in front of patients and guests.
• Value: ALWAYS… Value the time of others by striving to be on time, prepared and actively participating. Pick up trash, ensuring the physical environment is clean and safe. Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
• Engage: ALWAYS… Acknowledge wins and frequently thank team members and others for contributions. Show courtesy and compassion with customers, team members and the community.