Director, Utilization Review

Cincinnati Children's Hospital Medical Center; United States; On-site; USD 130,000 - 169,000; Full time

Job summary

Cincinnati Children's Hospital Medical Center is seeking a seasoned Utilization Review Manager to lead UR functions ensuring payer approvals for inpatient admissions and stays when clinically necessary. The role also interfaces with payers, supports the revenue cycle, and maintains UR standards across contracts and processes.

The position requires an RN with Ohio licensure, a nursing degree, and senior-level management experience.

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.

Responsibilities

• Utilization Review Management leads UR functions to ensure payers approve inpatient admissions and stays when needed.
• Directs department communications with payers to certify stays and challenges adverse determinations as appropriate.
• Ensures UR functions meet JCAHO/Medicaid/Medicare and payer standards and requirements.
• Educates and communicates with administration, department heads, physicians, and other groups on UR functions.
• Revenue Cycle Support: communicates with Medicaid/Medicare and third-party reviewers; assists with denials appeals.
• Payer Relations: develops relationships with payers and presents Cincinnati Children's offerings to them.
• Financial Management: manages annual operating budgets for UR department.

Skills

Nursing

Education

Bachelor's degree in nursing

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'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

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

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.