Remote Utilization Nurse: Optimize Care & Payer

TriHealth; Cincinnati (OH); Remote; USD 75,000 - 95,000; Full time

Benefits offered by this job

Comprehensive benefits package

Tuition reimbursement

Career growth opportunities

Job summary

TriHealth is seeking a Utilization Management (UM) Nurse to evaluate medical necessity and ensure care aligns with regulatory and payer requirements. You will collaborate with physicians, care management, and payers while working with EPIC, Outlook, TEAMS and Voalte.

Strong time management and self-discipline are essential for success. Required RN with an Associate's Degree; BSN must be pursued within 5 years.

Qualifications

• RN with an Associate's Degree is required.
• New hires must obtain BSN within 5 years of hire.
• 3–4 years of clinical nursing experience required.
• Registered Nurse on hire is required.
• Membership in related professional organization is preferred.

Responsibilities

• Performs initial and concurrent reviews to determine medical necessity using evidence-based criteria.
• Validates patient class (inpatient, observation, bedded outpatient) per CMS and payer requirements.
• Provides clinical information to payers in a timely manner; follows up to obtain authorization.
• Coordinates with interdisciplinary care team including physicians and care management.
• Documents delays in care and escalates as appropriate.

Skills

Time management

Self-directed

Communication

Problem solving

Team collaboration

Education

Associate's Degree - Nursing

BSN within 5 years

Tools

EPIC

Outlook

TEAMS

Voalte

Microsoft Word

Job description

TriHealth is seeking a Utilization Management (UM) Nurse to evaluate medical necessity and ensure care aligns with regulatory and payer requirements. You will collaborate with physicians, care management, and payers while working with EPIC, Outlook, TEAMS and Voalte.

Strong time management and self-discipline are essential for success. Required RN with an Associate's Degree; BSN must be pursued within 5 years.