Sr. Utilization Management Specialist (RN)

Cincinnati Children's

1d•$74,298 - $94,744•Remote

About The Position

This role is responsible for ensuring that Utilization Management Specialists follow set policies and processes for addressing authorization requests. The specialist will serve as the lead interface between the authorization processing team and Health Partners, Care Managers, and Discharge Planners. They will also provide oversight for non-clinical medical management staff. Key responsibilities include identifying and referring appropriate members for care management and quality issues, overseeing interrater reliability audits for Patient Care Coordinators, and using independent judgment to ensure templates are compliant with Federal, State, and Regulatory requirements. The role involves documenting, identifying, and communicating 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. Additionally, the specialist must meet third-party payer standards, maintain knowledge of changes impacting regulatory/accrediting compliance for reimbursement, and assist the Director in reporting information related to admissions and continued stay reviews. Participation in interdepartmental meetings to promote knowledge, troubleshoot, and resolve utilization management issues is expected. The specialist will also serve as an educational and communications resource regarding utilization management activities and processes, and keep the department manager informed of problems.

Requirements

Bachelor of Science in Nursing
5+ years of work experience in a related job discipline.
Current, unrestricted Registered Nurse (RN) Ohio licensure
Must reside within 70 miles of 45229, Cincinnati, OH.

Responsibilities

Ensure that Utilization Management Specialists follow set policies and processes for addressing authorization requests.
Lead interface between authorization processing team and Health Partners, Care Managers and Discharge Planners.
Provide oversight for non-clinical medical management staff.
Identify and refer appropriate members for care management and quality issues to Quality Improvement.
Oversees interrater reliability audits for Patient Care Coordinators.
Uses independent judgement to ensure templates are compliant with Federal, State and Regulatory requirements.
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.
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 under utilization 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.
Oversee audits and ensure staff feedback occur at regular intervals.
Analyze and formulate recommendations based on data and maintain utilization management reporting.
Oversight and assistance with documentation, identification, and communication with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination in a timely and cost-effective manner.