Senior Utilization Management Specialist, RN

This is a fully remote position, open to applicants in Ohio.

📋 Description

• Ensure that Utilization Management Specialists adhere to established policies and procedures for authorization requests.

• Facilitate communication between the authorization processing team and Health Partners, Care Managers, and Discharge Planners.

• Provide supervision for non-clinical medical management personnel.

• Identify members who require care management and quality issue referrals to Quality Improvement.

• Oversee interrater reliability audits for Patient Care Coordinators.

• Ensure that templates are in compliance with Federal, State, and Regulatory standards.

• Document, identify, and communicate discharge planning requirements and care coordination.

• Meet the standards and requirements set by third-party payers.

• Monitor the impact of regulatory and accrediting compliance on reimbursement.

• Assist the Director in reporting under the PI plan, including the appropriateness of admissions, continued stay reviews, and resource utilization.

• Engage in interdepartmental meetings to enhance knowledge and address utilization management challenges.

• Act as an educational and communication resource concerning utilization management activities and procedures.

• Keep the department manager updated on issues.

• Supervise audits and ensure consistent staff feedback.

• Analyze data, develop recommendations, and maintain utilization management reporting.

⛳️ Requirements

• Bachelor of Science in Nursing.

• 5+ years of experience in a related field.

• Current, unrestricted Registered Nurse (RN) licensure in Ohio.

• Must live within 70 miles of ZIP code 45229, Cincinnati, Ohio.

• Capability to oversee authorization processing, audits, utilization management reporting, and discharge planning coordination.

• Understanding of Federal, State, regulatory, accrediting, and third-party payer requirements.

🏝️ Benefits

• Additional pay may be available, including shift differentials, on-call, or weekend differentials.

• A comprehensive job description can be provided upon request.

• Reasonable accommodations are available for qualified individuals with disabilities.

• Equal opportunity employment environment dedicated to dignity and respect.