Primary Location
Remote
Department
PS HealthVine UM
Shift
Day (United States of America)
Schedule
Full time
Weekly Hours
40
FTE
1
Employee Status
Regular
*Expected Starting Pay Range
$74,297.60 - $94,744.00
*Starting pay is based on experience, skills, and equity; exceptions may apply for highly qualified candidates. Additional pay (e.g., shift, on‑call, or weekend differentials) and benefits may apply. Annual pay may vary based on FTE status.
JOB RESPONSIBILITIES
Leadership- Ensure that Utilization Management Specialists follow set policies and processes for addressing authorization requests. Lead interface between authorization processing team and Health Partners, Care Managers and Discharge Planners. Provide oversight for non-clinical medical management staff.
Quality- Identify and refer appropriate members for care management and quality issues to Quality Improvement. Oversees interrater reliability audits for Patient Care Coordinators. Uses independent judgement to ensure templates are compliant with Federal, State and Regulatory requirements.
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.
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 under utilization 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.
Quality- Oversee audits and ensure staff feedback occur at regular intervals. Analyze and formulate recommendations based on data and maintain utilization management reporting.
Oversight and assistance with documentation, identification, and communication with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination in a timely and cost-effective manner.
JOB QUALIFICATIONS
Bachelor of Science in Nursing
5+ years of work experience in a related job discipline.
Current, unrestricted Registered Nurse (RN) Ohio licensure
Must reside within 70 miles of 45229, Cincinnati, OH.
