RN Utilization Management Specialist II-HealthVine

Cincinnati Children's

10d•$67,538 - $86,112•Remote

About The Position

JOB RESPONSIBILITIES Utilization Management- Utilization Management: Independently working more complex prospective, retrospective and concurrent review and processing of authorization requests for inpatient admissions, outpatient procedures, homecare services and durable medical equipment. Generates required correspondence, including denial letters, based on medical necessity and administrative review process while maintaining productivity and turnaround time. Quality- Work with management team to ensure 100% correct letter and less than 2% error rate are met. Uses independent judgement to ensure templates are compliant with Federal, State and Regulatory requirements. Identify and refer appropriate members for care management and quality issues to Quality Improvement. Recommends process improvements and provides documentation for processes to the department. Discharge Planning- Document, identify and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care in a timely and cost-effective manner. Interfaces with physician reviewers to optimize the written communication to members and referring providers. Compliance- Meet third-party payer standards and requirements. Maintains knowledge of changes as impacts regulatory/accrediting compliance for reimbursement. Assist Director in the reporting of information as set forth in the PI plan, i.e., appropriateness of admissions and continued stay reviews including when known, the over and underutilization of resources. Participate in interdepartmental meetings to promote knowledge, troubleshoot, problem shoot and resolve issues as relates to utilization management. Serves as an educational and communications resource to Administration, Department heads, physicians and other necessary groups regarding the utilization management activity and process. Keep the department manager informed of problems, as necessary. Leadership- Provide guidance to and assist with oversight of non-clinical staff, including training and education of Specialist I. Act as a primary point of contact for the Utilization Management team. Answers questions and provide guidance for difficult reviews and processes. Responsible for required correspondence. Using professional education independently documents, identifies and communicates with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care in a timely and cost-effective manner.

Requirements

Bachelor of Science in Nursing
3+ years of work experience in a related job discipline.
Current, unrestricted Registered Nurse (RN)
Candidate must live within 70 miles of Cincinnati, OH-45229

Responsibilities

Independently working more complex prospective, retrospective and concurrent review and processing of authorization requests for inpatient admissions, outpatient procedures, homecare services and durable medical equipment.
Generates required correspondence, including denial letters, based on medical necessity and administrative review process while maintaining productivity and turnaround time.
Work with management team to ensure 100% correct letter and less than 2% error rate are met.
Uses independent judgement to ensure templates are compliant with Federal, State and Regulatory requirements.
Identify and refer appropriate members for care management and quality issues to Quality Improvement.
Recommends process improvements and provides documentation for processes to the department.
Document, identify and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care in a timely and cost-effective manner.
Interfaces with physician reviewers to optimize the written communication to members and referring providers.
Meet third-party payer standards and requirements.
Maintains knowledge of changes as impacts regulatory/accrediting compliance for reimbursement.
Assist Director in the reporting of information as set forth in the PI plan, i.e., appropriateness of admissions and continued stay reviews including when known, the over and underutilization of resources.
Participate in interdepartmental meetings to promote knowledge, troubleshoot, problem shoot and resolve issues as relates to utilization management.
Serves as an educational and communications resource to Administration, Department heads, physicians and other necessary groups regarding the utilization management activity and process.
Provide guidance to and assist with oversight of non-clinical staff, including training and education of Specialist I.
Act as a primary point of contact for the Utilization Management team.
Answers questions and provide guidance for difficult reviews and processes.
Responsible for required correspondence.
Using professional education independently documents, identifies and communicates with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care in a timely and cost-effective manner.