Utilization and Appeals Coordinator

Job Overview:

This position may perform utilization management functions on a prospective, concurrent or retrospective basis in order to maximize revenue for TriHealth. This includes analysis of clinical information presented with comparison to established national clinical criteria to determine appropriate place of service such as inpatient/outpatient/observation and medical necessity for ongoing inpatient care. In addition, understands all government and health plan requirements while negotiating with health plan to obtain authorization for services or payment on denied claims, pre-pay and post pay audit review. This staff works independently with a high level of autonomy and decision making surrounding high dollar services and revenue.

Job Requirements:

Associate's Degree or Diploma in Nursing
New hires required to obtain BSN within 5 years of hire
Registered Nurse
Current Ohio licensure
5-7 years experience Clinical in Nursing hospital based

Job Responsibilities:

Teamwork, communication, problem solving, conflict resolution.
Risk management
Assesses and analyzes quality indicators, documents them, and differentiates between morbidity and mortality outcomes. Reports as indicated to manager, medical dir.
Identifies areas for self improvement, maintains areas of current practice, supports organizational activities.
Applies the principals of UR in processes of admission orders, levels of care, documents current status, communicates with attending physicians.

Other Job-Related Information:

Working Conditions:

Climbing - Rarely
Concentrating - Consistently
Continous Learning - Consistently
Hearing: Conversation - Consistently
Hearing: Other Sounds - Consistently
Interpersonal Communication - Consistently
Kneeling - Occasionally
Lifting <10 Lbs - Consistently
Lifting 50 Lbs - Rarely
Lifting 11-50 Lbs - Consistently
Pulling - Consistently
Pushing - Consistently
Reaching - Consistently
Reading - Consistently
Sitting - Frequently
Standing - Occasionally
Stooping - Occasionally
Talking - Consistently
Thinking/Reasoning - Consistently
Use of Hands - Consistently
Color Vision - Consistently
Visual Acuity: Far - Consistently
Visual Acuity: Near - Consistently
Walking - Frequently

TriHealth SERVE Standards and ALWAYS Behaviors
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:

Serve: ALWAYS…

Welcome everyone by making eye contact, greeting with a smile, and saying "hello"

Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist

Refrain from using cell phones for personal reasons in public spaces or patient care areas

Excel: ALWAYS…

Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met

Offer patients and guests priority when waiting (lines, elevators)

Work on improving quality, safety, and service

Respect: ALWAYS…

Respect cultural and spiritual differences and honor individual preferences.

Respect everyone’s opinion and contribution, regardless of title/role.

Speak positively about my team members and other departments in front of patients and guests.

Value: ALWAYS…

Value the time of others by striving to be on time, prepared and actively participating.

Pick up trash, ensuring the physical environment is clean and safe.

Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.

Engage: ALWAYS…

Acknowledge wins and frequently thank team members and others for contributions.

Show courtesy and compassion with customers, team members and the community