Pediatric Utilization Manager & Pre-Cert Specialist

East Tennessee Children's Hospital; Knoxville (TN); On-site; USD 65,000 - 85,000; Full time

Job summary

East Tennessee Children's Hospital is seeking a Utilization Review Coordinator to perform pre-certification and extended stay reviews for admitted patients. The role ensures timely pre-certification for inpatient, observation, and same-day surgery cases and communicates with insurance providers.

The ideal candidate has RN and/or RHIA credentials with at least 2 years of utilization review experience and strong knowledge of Meditech, Trace Products, and insurance processes.

Qualifications

• Knowledge of medical terminology, anatomy & physiology and pediatric nursing experience.
• Excellent communication skills.
• Detail-oriented with organizational and time management skills.
• Proficient in computers, word processing and computer applications.
• Problem solving skills.
• Proficient in the use of reference materials and resources.

Responsibilities

• Obtains initial pre-certification review for all admissions admitted through the emergency room; notifies insurance companies of patient admission; reviews and submits patient clinical to insurance companies per policy.
• Verifies and/or obtains pre-certification for all admissions admitted directly from physician office; performs extend stay reviews for all patients; obtains other pre-certification reviews for procedures that are required by insurance.
• Enters the pre-certification number and days approved into Meditech; enters extended days; updates Meditech with next clinical update.
• Maintains paper and electronic utilization review records.
• Uses Meditech, Trace Products and insurance websites to obtain precertification; participates in discharge planning.
• Processes appeals (concurrent, retrospective, second-level) for denied accounts; ensures accuracy and timeliness.
• Provides training for new utilization management coordinators; maintains program compliance with laws and regulations.
• Interacts with physicians, physician advisors, and insurance representatives professionally.
• Maintains confidentiality of hospital and patient information; supports customer service goals.

Skills

Medical terminology

Anatomy & physiology

Pediatric nursing experience

Computer proficiency

Problem solving

Education

Associates Degree

Bachelor's degree preferred

Degree in Nursing or Health Information Administration

Tools

Meditech

Trace Products

Job description

East Tennessee Children's Hospital is seeking a Utilization Review Coordinator to perform pre-certification and extended stay reviews for admitted patients. The role ensures timely pre-certification for inpatient, observation, and same-day surgery cases and communicates with insurance providers.

The ideal candidate has RN and/or RHIA credentials with at least 2 years of utilization review experience and strong knowledge of Meditech, Trace Products, and insurance processes.