[Hiring] Utilization Review Specialist @Cincinnati Children's

Role Description

The primary responsibilities of this role include:

• Case Management:
  • Perform admission and continued stay reviews on patients to determine medical necessity.
  • Utilize the approved medical management criteria tool (e.g., Interqual).
  • Record all required documentation on patient review forms and in computerized systems.
  • Maintain pertinent statistical data as required by the department.
  • Interface with the Admitting Department and Financial Counseling departments to identify correct insurance and coordination of benefits.
  • Communicate with third party payers to certify inpatient stays.
  • Recognize issues that potentially cause delays in discharge.
• Authorization Process:
  • Facilitate interaction between medical center personnel and payer personnel to overturn denials.
  • Assist with retrospective review of records for patients with insurance changes.
  • Work with Revenue Management Cycle members to obtain reimbursement through revised/new certifications.
  • Review timeliness, accuracy, and security of new information.
• Compliance:
  • Assist Director in meeting JCAHO, Medicaid, Medicare, and other payer standards.
  • Maintain knowledge of changes impacting regulatory/accrediting compliance.
  • Participate in meetings to promote knowledge and resolve issues related to utilization management.
  • Serve as an educational resource regarding the utilization review/management process.
• Training & Education:
  • Serve as an educational resource to Administration, Department heads, physicians, and other necessary groups.

Qualifications

• Bachelor's degree in a related field.
• 2+ years of work experience in a related job discipline.
• Current, unrestricted Registered Nurse (RN), Social Work or Clinical Counselor Licensure in the state(s) of practice.
• Preferred: Experience with Payers (Commercial and Government).

Requirements

• Ability to perform admission and continued stay reviews.
• Proficient in using medical management criteria tools.
• Strong communication skills with third party payers and healthcare teams.
• Knowledge of JCAHO, Medicaid, Medicare, and other payer standards.

Benefits

• Expected starting pay range: $69,388.80 - $88,608.00.
• Additional pay (e.g., shift, on-call, or weekend differentials) may apply.
• Comprehensive benefits package available.