Director, Utilization Review

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

Primary Location

South Campus

Department

Utilization Review

Shift

Day (United States of America)

Schedule

Full time

Weekly Hours

40

FTE

1

Employee Status

Regular

*Expected Starting Pay Range

$129,563.20 - $168,688.00

*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

• Utilization Review Management- leads utilization review functions for CCHMC to ensure that third party payers approve inpatient admissions and continued inpatient stays when clinicians deem it necessary. Directs department’s communications with third party payers to certify inpatient stays and challenges adverse determinations when appropriate. Insures utilization review functions meet current JCAHO Medicaid, Medicare and third party payer standards and requirements. Serves as an educational and communications resource to administration, department heads, physicians, and other necessary groups regarding utilization review functions.
• Revenue Cycle Support- Communicates with Medicaid/Medicare and other third-party review organizations as regulations and rules require and concerns arise. Assist with appeals of denials as quested, Analyzes and interprets utilization management language in third party contracts and makes recommendations as requested by senior management.
• Payer Relations- Develop and maintain appropriate working relationships with decision-makers and operating/clinical departments of third-part payers, insurance companies, employers, 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.
• Financial Management- Manage the annual operating expense budgets of departments/costs centers reporting to position.

JOB QUALIFICATIONS

• 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

PREFERRED JOB QUALIFICATIONS

• Prior management experience in UR (provider side) or UM (payor side)- 3+ years
• Experience with process improvement processes
• Experience with a Physician Advisor Program
• Experience with inpatient psychiatric stays (would be a bonus)
• Experience/general knowledge of AI tools in the UR/UM space

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 (2025) , America’s Best Employers for New Grads (2025)

• One of the nation’sAmerica’s Most Innovative Companiesas noted by Fortune

• Consistently certified as great place to work

• A Leading Disability Employeras noted by theNational Organization on Disability

• Magnet® designated for the fourth consecutive time by theAmerican 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