Talent.com
Utilization Management Specialist II
Utilization Management Specialist IICincinnati Children's Hospital Medical Center • Cincinnati, Ohio, United States
Utilization Management Specialist II

Utilization Management Specialist II

Cincinnati Children's Hospital Medical Center • Cincinnati, Ohio, United States
[job_card.30_days_ago]
[job_preview.job_type]
  • [job_card.full_time]
[job_card.job_description]
Utilization Management Specialist II-154905

Description

Utilization Management Specialist

Full-time 40 hr/week - remote after orientation with onsite requirements as needed and in the Greater Cincinnati Area.

May require some brief case checks during holiday times.

Expected Starting Salary Range: 31.43 - 39.59
Utilization Management program is to assure that all members receive all medically necessary services at the appropriate level and setting of care in a timely, efficient manner. The Medical Management Program evaluates the appropriateness of care, over and underutilization of both inpatient and outpatient services, and provides ongoing performance feedback to the Managed Care Plan derived from prospective, concurrent, and retrospective review of clinical information.

Scope: 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.


REPRESENTATIVE 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.

Qualifications

EDUCATION/EXPERIENCE


Required: Bachelor of Science in Nursing or Master's Degree in Social Work, Counseling, or related field3 years of work experience in a related job discipline.Current, unrestricted Registered Nurse (RN), Social Work or Clinical Counselor Licensure in state(s) of practice Preferred: Prefer Utilization Management / Managed Care and Pediatric experience.
Cincinnati Children's is proud to be an Equal Opportunity Employer that values and treasures Diversity, Equity, and Inclusion. We are committed to creating an environment of dignity and respect for all our employees, patients, and families. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, genetic information, national origin, sexual orientation, gender identity, disability or protected veteran status. EEO/AA/M/F/Veteran/Disability

Job

Nursing/Clinical

Shift

Day Job

Job Type

StandardDepartmentHealthVine Utilization Mgmt

Employee Status

Regular
FTE
1.0
Weekly Hours
40

Salary Range

31.43-47.74
[job_alerts.create_a_job]

Utilization Management Specialist II • Cincinnati, Ohio, United States

[internal_linking.similar_jobs]

Travel Echo Tech - $2,728 per week in Fairfield, OH

AlliedTravelCareersFairfield, OH, US
[job_card.full_time]

AlliedTravelCareers is working with CrossMed Healthcare Staffing to find a qualified Echo Tech in Fairfield, Ohio, 45014!.At CrossMed Healthcare Staffing, we aim to create lasting impressions where...[internal_linking.show_more]

 • [job_card.promoted]

Assistant Store Manager

Community Choice Financial Family of BrandsDry Ridge, KY, US
[job_card.full_time]

As an Assistant Store Manager (ASM), you’ll support our customers through real financial needs while gaining hands-on experience running a store.You’ll develop your leadership skills in real-time b...[internal_linking.show_more]

 • [job_card.promoted]

Work from Home – Product Feedback Support - $25-$45 per hour

GLGlencoe, Kentucky
[filters.remote]
[job_card.full_time]

We’re looking for Customer Support Product Testers across the US to work from home and help top brands improve their products before they hit the market.[internal_linking.show_more]

 • [job_card.promoted]

Operations Specialist Mortgage Warehouse

TALENT Software ServicesCincinnati, OH, United States
[job_card.full_time]

Operations Specialist Mortgage Warehouse.Talent Software Services is in search of a Project Manager: Customer Success, Implementations for a contract position in Cincinnati, OH.The opportunity will...[internal_linking.show_more]

 • [job_card.promoted]

Advanced Medical Support Assistant

Department of Veterans AffairsHamilton, OH, United States
[job_card.permanent]

The Cincinnati VA Medical Center is seeking dedicated professionals to join our team of Advanced Medical Support Assistants serving our Veterans.This is an open-continuous announcement, applicants ...[internal_linking.show_more]

 • [job_card.promoted]

Metered Utilities Specialist

London Computer Systems (LCS)Cincinnati, OH, United States
[job_card.full_time]

Are you someone who enjoys research and has a keen eye for detail? Do you enjoy math and equations? Are you one who enjoys analyzing data trends and finding anomalies in those trends? Do you enjoy ...[internal_linking.show_more]

 • [job_card.promoted]

Utilization Management Representative II (Virtual in Ohio)

CareBridgeCincinnati, OH, United States
[job_card.full_time]

Utilization Management Representative II Schedule: Monday-Friday 8am-5pm Eastern Time Must be located in the state of Ohio Virtual: This role enables associates to work virtually full-time, with th...[internal_linking.show_more]

 • [job_card.promoted]

Continuous Improvement Specialist II

Regal RexnordFlorence, KY, United States
[job_card.full_time]

Regal Business Systems Specialist.The Regal Business Systems (RBS) Specialist assists the RBS Site Leader driving operational excellence across all areas of the site supporting SQDCG (safety, quali...[internal_linking.show_more]

 • [job_card.promoted]

Senior EHS Manager

Bunzl Plc.Fairfield, OH, United States
[job_card.full_time]

The Senior EHS Manager is responsible for leading and executing the Environmental, Health & Safety (EHS) strategy for the Distribution Division in alignment with corporate EHS objectives.This role ...[internal_linking.show_more]

 • [job_card.promoted]

Culinary Specialist - Grant Healthcare and Rehabilit - Food

Aramark CorporationWilliamstown, KY, United States
[job_card.full_time]

Prepare quality food and baked goods according to a planned menu Prepare a daily report that verifies transactions Understand what is inclusive of a meal Ensure storage of food in an accurate and s...[internal_linking.show_more]

 • [job_card.promoted]

Domestic Operations Specialist

ATALNTErlanger, KY, United States
[job_card.full_time]

Domestic Operations Specialist.A transportation and logistics organization is seeking a strong Domestic Operations professional based in the Cincinnati / Northern Kentucky market.This is a fully on...[internal_linking.show_more]

 • [job_card.promoted]

Management Analyst (Travel Specialist)

US Government JobsCincinnati, OH, United States
[job_card.full_time]

This position is in the Office of the Administrator (AO), Office of the Administrative Service and Performance Management, Business Operations Division.This is an office-centered position--you must...[internal_linking.show_more]

 • [job_card.promoted]

Rate Management Specialist

FBT Gibbons LLPCincinnati, OH, United States
[job_card.full_time]

FBT Gibbons LLP is a national law firm focused on serving companies operating and investing in the middle market.With nearly 1,500 employees across 25 offices, we support clients ranging from large...[internal_linking.show_more]

 • [job_card.promoted]

Mail Carrier - City - No Experience Required

Postal Jobs AssistCrittenden, Kentucky, United States
[job_card.full_time]

USPS is accepting applications for City Carrier Assistants nationwide.This role ensures smooth postal operations by delivering mail efficiently.No prior experience is required, as USPS offers compr...[internal_linking.show_more]

 • [job_card.promoted]

Magnet Program Manager - Administration - The Jewish Hospital

Mercy HealthCincinnati, OH, United States
[job_card.full_time]

Thank you for considering a career at Mercy Health! Scheduled Weekly Hours: 40 Work Shift: Days/Afternoons (United States of America) Program Manager - Administration - The Jewish Hospital 40 hours...[internal_linking.show_more]

 • [job_card.promoted]

Dialysis Operations Director - San Antonio, TX (Relocation Assistance Available)

University HealthCINCINNATI, Ohio, United States
[job_card.full_time]

At University Health, we are dedicated to improving the health of our community through exceptional patient care, education, and innovation.Our team embodies a strong commitment to excellence, and ...[internal_linking.show_more]

 • [job_card.promoted]

Intermodal Equipment Operator

ConGlobalDry Ridge, Kentucky, United States
[job_card.full_time]

Launch Your Career with ConGlobal.Whether you're looking to grow your career or gain new skills, this role offers.Cherry Blossom Way Georgetown, Kentucky 40324 United States.Status: Full-Time Immed...[internal_linking.show_more]

 • [job_card.promoted] • [job_card.new]

Integrated Health Management Manager

AccentureCincinnati, OH, United States
[job_card.full_time]

Job Description Accenture is a global leader in professional services, helping organizations worldwide transform their operations, enhance their growth, and deliver sustainable outcomes across indu...[internal_linking.show_more]