Director, Utilization Review & Payer Strategy

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

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.