Utilization Review Specialist

Job Responsibilities

• Case Management- Perform admission and continued stay reviews on patients to determine the medical necessity of severity of illness and intensity of service for certification of admission and continued stay. This is done utilizing the approved medical management criteria tool i.e. Interqual. Record all required documentation on patient review forms and in computerized systems to maintain a record of the review and the coverage obtained for a patient. Maintain pertinent statistical data as required by the department. Interface with the Admitting Department and/or the Financial Counseling departments to identify correct insurance, coordination of benefits information, effective dates of coverage, pre/admission notifications/authorizations for certification of inpatient admissions. Interface with other members of the health-care team regarding the implementation of discharge planning and the certification justification documentation of patient stays, advising them of external/third party requirements and criteria. Communicates with third party payers to certify inpatient stays. Using data extrapolated from electronic systems, attempt to recognize issues that potentially cause a delay in discharge i.e. poor documentation of SI/IS, delay days and the cause thereof etc.
• Authorization Process- Works closely with respective parties within the organization to facilitate interaction between medical center personnel and payer personnel to overturn potential and/or final denials. Assists with the retrospective review of records for patients who have insurance changes that impact the authorization of the inpatient encounter. Works with identified Revenue Management Cycle members to obtain reimbursement through the revised/new certification of patient stays. Reviews timeliness, accuracy and security of new information.
• Compliance- Assist Director in meeting current JCAHO, Medicaid, Medicare, and other third-party payer standards and requirements. Maintains knowledge of changes as impacts regulatory/accrediting compliance for reimbursement. Assist Director in the reporting of information as set forth in the PI plan, i.e., appropriateness of admissions and continued stay reviews including when known, the over and under utilization of resources. Participate in payer, Revenue Management Cycle and interdepartmental meetings to promote knowledge, troubleshoot, problem shoot and resolve issues as relates to utilization management. Serves as an educational and communications resource to Administration, Department heads, physicians and other necessary groups regarding the utilization review/management activity and process. Keep the department manager informed of problems as necessary.
• Training & Education- Serves as an educational and communications resource to Administration, Department heads, physicians, and other necessary groups regarding Utilization Review.
  
  

Job Qualifications

• Bachelor's degree in a related field
• 2 years of work experience in a related job discipline
• Current, unrestricted Registered Nurse (RN), Social Work or Clinical Counselor Licensure in the state(s) of practice
  
  

Primary Location

South Campus

Schedule

Full time

Shift

Day (United States of America)

Department

Utilization Review

Employee Status

Regular

FTE

0.8

Weekly Hours

32

• Expected Starting Pay Range
• Annualized pay may vary based on FTE status $67,537.60 - $86,112.00
  
  

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