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Cincinnati Children’s Hospital and Medical Center

Pediatric hospital, research, and medical education

Director Utilization Review

Medical, Clinical & VeterinaryConfirmed live in the last 24 hours
Full-timeUnited States$129.6k - $168.7k /yrIn-person

About the Job

Requirements

  • A bachelor's degree in nursing is required.
  • At least 5 years of work experience in a related job discipline is required.
  • At least 4 years of frontline management experience is required.
  • An active Ohio RN license is required.

Responsibilities

  • Lead utilization review functions to ensure third-party payers approve inpatient admissions and continued inpatient stays when clinicians deem them necessary.
  • Direct communications with third-party payers to certify inpatient stays and challenge adverse determinations when appropriate.
  • Ensure utilization review functions meet current JCAHO, Medicaid, Medicare, and third-party payer standards and requirements.
  • Serve as an educational and communications resource to administration, department heads, physicians, and other necessary groups regarding utilization review functions.
  • Communicate with Medicaid, Medicare, and other third-party review organizations as regulations, rules, and concerns arise.
  • Assist with appeals of denials as requested.
  • Analyze and interpret utilization management language in third-party contracts and make recommendations as requested by senior management.
  • Develop and maintain appropriate working relationships with decision-makers and operating and clinical departments of third-party payers, insurance companies, employers, and federal, state, local, international government and private payers.
  • Conduct presentations and market Cincinnati Children's and PHO to third-party payers, government officials, and employers.
  • Manage the annual operating expense budgets of departments and cost centers reporting to the position.

Desired Qualifications

  • Prior management experience in utilization review on the provider side or utilization management on the payer side, with at least 3 years of experience.
  • Experience with process improvement processes.
  • Experience with a Physician Advisor Program.
  • Experience with inpatient psychiatric stays.
  • Experience or general knowledge of artificial intelligence tools in the utilization review or utilization management space.

About the Company

Cincinnati Children’s Hospital and Medical Center

Pediatric hospital, research, and medical education

Cincinnati Children’s Hospital Medical Center is a nonprofit academic medical center that provides pediatric care across the spectrum—from routine well-child visits to treatment of rare and complex illnesses—and serves as the Department of Pediatrics for the University of Cincinnati College of Medicine. Care is delivered by pediatric specialists in hospital and clinic settings, while researchers and educators translate findings into better treatments and train residents and fellows. It differentiates itself by combining patient care with university-backed pediatric research and education at scale, along with a commitment to equality and an inclusive environment for staff, patients, and families. Its goal is to improve child health by delivering high-quality care, advancing medical knowledge through research, and training the next generation of pediatric professionals.

Company size
10,001+
Company stage
Grant
Total funding
$18.4M
Headquarters
Cincinnati, OH
Founded
1883

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