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Job Description At Cincinnati Children's, we come to work with one goal: to make children's health better. We believe in a holistic team approach, both in caring for patients and their families, and in advancing science and discovery. We strive to do better and find energy and inspiration in our shared purpose. If you want to be the best you can be, you can do it at Cincinnati Children's. Cincinnati Children's Hospital Has Been Named: * The #1 Pediatric Hospital in the Nation - US News and World Report 2023 * One of four Medical Centers making the list of the 2022 Glassdoor Best Places to Work * A Top Hospital and Health System for Diversity recognized by DiversityInc * One of the nation's most innovative companies by Fortune in March 2023 * An LGBTQ+ Healthcare Equality Top Performer in 2022 by The Human Rights Campaign (HRC) 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. JOB QUALIFICATIONS * Bachelor of Science in Nursing or Master's Degree in Social Work, Counseling, or related field * 3+ 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 Market LeadiApply here: https://www.aplitrak.com/?adid=YmJnZW5lcmljLjY5NDU2LjEwNTA4QGNpbmNpbm5hdGljaGlsZHJlbnNjb21wLmFwbGl0cmFrLmNvbQ