Director of Utilization Review & Payer Strategy

Cincinnati Children's Hospital Medical Center; Mount Vernon (VA); On-site; USD 130,000 - 169,000; Full time

Job summary

Cincinnati Children’s Hospital is seeking an experienced leader in Utilization Review to oversee UR operations at the South Campus. The role ensures appropriate approvals for inpatient admissions and stays, directs communications with third-party payers, and provides education to administration, physicians, and department heads on utilization review standards.

The position also supports revenue cycle activities, engages with Medicaid/Medicare and payers, and develops strong payer relationships

Qualifications

• Bachelor’s degree in nursing is required.
• 5+ years of work experience in a related job discipline.
• 4 years frontline management experience.
• Active RN License in Ohio.

Responsibilities

• Utilization Review Management- leads utilization review functions to ensure third party payers approve inpatient admissions and continued stays when clinicians deem it necessary.
• Revenue Cycle Support- communicates with Medicaid/Medicare and other third-party review organizations; assist with appeals of denials; analyzes utilization management language in third party contracts.
• Payer Relations- develop and maintain relationships with third party payers, government and employers; conduct presentations and market to payers.
• Financial Management- manage the annual operating expense budgets of departments/cost centers reporting to position.

Education

Bachelor’s degree in nursing

5+ years of work experience in a related job discipline

4 years frontline management experience

Active RN License in Ohio

Job description

Cincinnati Children’s Hospital is seeking an experienced leader in Utilization Review to oversee UR operations at the South Campus. The role ensures appropriate approvals for inpatient admissions and stays, directs communications with third-party payers, and provides education to administration, physicians, and department heads on utilization review standards.

The position also supports revenue cycle activities, engages with Medicaid/Medicare and payers, and develops strong payer relationships