Pediatric Utilization Management Specialist

01 ETCH East Tennessee Children's Hospital Association, Inc.; United States; On-site; USD 65,000 - 90,000; Full time

Job summary

East Tennessee Children's Hospital seeks a Utilization Review Coordinator to perform pre-certification and extended stay reviews for inpatient and observation admissions, ensuring timely approvals. The role reports to Health Information Management and requires nursing or RHIA credentials with RN/RHIA licensure and 2+ years in Utilization Review.

The candidate will communicate with insurers, maintain Meditech records, assist in discharge planning, and support appeals and committee activities

Qualifications

• Associates degree required; Bachelor's degree preferred.
• RN and/or RHIA license/certification required.
• 2+ years of Utilization Review experience.

Responsibilities

• Obtain initial pre-certification review for all admissions via ER.
• Notify insurance companies of patient admission.
• Review and submit patient clinical information to insurers.
• Verify pre-certification for admissions from physician offices.
• Perform extended stay reviews for all patients.
• Obtain additional pre-certification reviews for procedures per policy.
• Communicate patient account information with relevant departments.
• Enter precertification numbers and days approved into Meditech; update next clinical date.
• Maintain paper and electronic utilization review records.
• Utilize Meditech, Trace Products, and insurance websites to obtain precertification.
• Participate in discharge planning.
• Process concurrent and retrospective appeals as appropriate.
• Support Utilization Management Committee and provide training on systems.

Skills

Medical terminology

Anatomy & physiology

Pediatric nursing experience

Excellent communication skills

Detail-oriented

Computers/word processing

Problem solving

Reference materials

Education

Associates Degree

Bachelors degree preferred

Nursing or Health Information Administration degree

RN and/or RHIA license/certification

2+ years Utilization Review experience

Job description

East Tennessee Children's Hospital seeks a Utilization Review Coordinator to perform pre-certification and extended stay reviews for inpatient and observation admissions, ensuring timely approvals. The role reports to Health Information Management and requires nursing or RHIA credentials with RN/RHIA licensure and 2+ years in Utilization Review.

The candidate will communicate with insurers, maintain Meditech records, assist in discharge planning, and support appeals and committee activities