Utilization Registered Nurse

TriHealth•Cincinnati, OH

3d•Remote

About The Position

The Utilization Management Nurse evaluates medical necessity to ensure care is delivered at the appropriate level and aligns with regulatory and payer requirements. The nurse collaborates with physicians, care management, and payers to obtain authorization for provided services. The role reports to the Supervisor or Manager of Utilization Management and requires autonomous work, strong time-management skills, and self-discipline. Candidates should be familiar with Microsoft Outlook, Microsoft Word, Teams, EPIC, and Voalte. This is a remote, full-time position with a day-shift schedule of 80 hours biweekly. TriHealth describes its mission as advancing healthcare and improving lives and offers career growth opportunities and a comprehensive benefits package.

Requirements

Associate degree in Nursing required.
New hires are required to obtain a BSN within five years of hire.
Three to four years of clinical nursing experience required.
Registered Nurse credential required upon hire.
Knowledge of specialty patient care guidelines.
Basic computer skills.
Problem-solving skills.
Ability to establish effective working relationships with healthcare team members and external customers.
Prior experience in a self-directed position.
Strong time-management skills and self-discipline to work autonomously.
Familiarity with Microsoft Outlook, Microsoft Word, Teams, EPIC, and Voalte.

Nice To Haves

Membership in a related professional organization.

Responsibilities

Perform initial and concurrent reviews to determine medical necessity using evidence-based criteria.
Validate the appropriate patient class—inpatient, observation, or bedded outpatient—based on CMS regulations, payer requirements, and department protocol.
Provide initial and concurrent clinical information to payers within required timelines and follow up as needed to obtain authorization.
Coordinate with the interdisciplinary care team, including attending physicians, physician advisors, and care management.
Recognize and document delays in care and escalate them as appropriate.
Demonstrate TriHealth SERVE Standards and ALWAYS Behaviors in interactions with patients, guests, team members, and the community.