Utilization Management Specialist-Remote within 50 miles of Cincinnati, OH

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

Primary Location Remote

Schedule Full time

Shift Day (United States of America)

Department PS HealthVine UM

Employee Status Regular

FTE 1

Weekly Hours 40

• Expected Starting Pay Range *Annualized pay may vary based on FTE status $67, $86,112.00

Market Leading Benefits Including*:

Medical coverage starting day one of employment. View employee benefits here.

Competitive retirement plans

Tuition reimbursement for continuing education

Expansive employee discount programs through our many community partners

Shift Differential, Weekend Differential, and Weekend Option Pay Programs for qualified positions

Support through Employee Resource Groups such as African American Professionals Advisory Council, Asian Cultural and Professional Group, EQUAL - LGBTQA Resource Group, Juntos - Hispanic/Latin Resource Group, Veterans and Military Family Advocacy Network, and Young Professionals (YP) Resource Group

Physical and mental health wellness programs

Relocation assistance available for qualified positions

• Benefits may vary based on FTE Status and Position Type

About Us

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 is:

Recognized by U.S. News & World Report as a top 10 best Children's Hospitals in the nation for more than 15 years

Consistently among the top 3 Children's Hospitals for National Institutes of Health (NIH) Funding

Recognized as one of America's Best Large Employers , America's Best Employers for New Grads (2025)

One of the nation's America's Most Innovative Companies as noted by Fortune

Consistently certified as great place to work

A Leading Disability Employer as noted by the National Organization on Disability

Magnet designated for the fourth consecutive time by the American Nurses Credentialing Center (ANCC)

We Embrace Innovation—Together. We believe in empowering our teams with the tools that help us work smarter and care better. That's why we support the responsible use of artificial intelligence. By encouraging innovation, we're creating space for new ideas, better outcomes, and a stronger future—for all of us.

Comprehensive job description provided upon request.

Cincinnati Children's is proud to be an Equal Opportunity Employer 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/Veteran/Disability