Director, Utilization Review
About The Position
The Director, Utilization Review leads Cincinnati Children’s utilization review functions to help ensure third-party payers approve inpatient admissions and continued inpatient stays when clinicians determine they are necessary. The position directs communications with payers to certify inpatient stays and challenges adverse determinations when appropriate. It ensures utilization review functions meet current JCAHO, Medicaid, Medicare, and third-party payer standards and requirements, and serves as an educational and communications resource for administration, department heads, physicians, and other groups. The role supports the revenue cycle by communicating with Medicaid, Medicare, and other third-party review organizations as required by regulations or as concerns arise. It assists with appeals of denials and analyzes and interprets utilization management language in third-party contracts, making recommendations as requested by senior management. The Director develops and maintains working relationships with decision-makers and operating or clinical departments at third-party payers, insurance companies, employers, and federal, state, local, international government, and private payers. The role also presents and markets Cincinnati Children’s and PHO to payers, government officials, and employers, and manages the annual operating expense budgets for the departments and cost centers reporting to the position.
Requirements
- Bachelor’s degree in nursing.
- At least 5 years of work experience in a related job discipline.
- At least 4 years of frontline management experience.
- Active RN license in Ohio.
Nice To Haves
- At least 3 years of prior management experience in utilization review on the provider side or utilization management on the payer side.
- Experience with process improvement processes.
- Experience with a Physician Advisor Program.
- Experience with inpatient psychiatric stays.
- Experience with or general knowledge of AI tools in the utilization review/utilization management space.
Responsibilities
- Lead utilization review functions to support payer approval of clinically necessary inpatient admissions and continued inpatient stays.
- Direct communications with third-party payers to certify inpatient stays and challenge adverse determinations when appropriate.
- Ensure utilization review functions meet current JCAHO, Medicaid, Medicare, and third-party payer standards and requirements.
- Provide education and communication about utilization review functions to administration, department heads, physicians, and other necessary groups.
- Communicate with Medicaid, Medicare, and other third-party review organizations as required by regulations and as concerns arise.
- Assist with appeals of denials.
- Analyze and interpret utilization management language in third-party contracts and make recommendations as requested by senior management.
- Develop and maintain working relationships with decision-makers and operating or clinical departments at payers, insurance companies, employers, government entities, and private payers.
- Conduct presentations and market Cincinnati Children’s and PHO to third-party payers, government officials, and employers.
- Manage annual operating expense budgets for departments and cost centers reporting to the position.
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What This Job Offers
Job Type
Full-time
Career Level
Director
