Sr. Utilization Management Specialist (RN)

Primary Location

Remote

Department

PS HealthVine UM

Shift

Day (United States of America)

Schedule

Full time

Weekly Hours

40

FTE

1

Employee Status

Regular

*Expected Starting Pay Range

$74,297.60 - $94,744.00

*Starting pay is based on experience, skills, and equity; exceptions may apply for highly qualified candidates. Additional pay (e.g., shift, on?call, or weekend differentials) and benefits may apply. Annual pay may vary based on FTE status.

JOB RESPONSIBILITIES

• Leadership-Ensure that Utilization Management Specialists follow set policies and processes for addressing authorization requests. Lead interface between authorization processing team and Health Partners, Care Managers and Discharge Planners. Provide oversight for non-clinical medical management staff.

• Quality-Identify and refer appropriate members for care management and quality issues to Quality Improvement. Oversees interrater reliability audits for Patient Care Coordinators. Uses independent judgement to ensure templates are compliant with Federal, State and Regulatory requirements.

• Discharge Planning-Document, identify and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care in a timely and cost-effective manner.

• Compliance-Meet 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 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 management activity and process. Keep the department manager informed of problems as necessary.

• Quality-Oversee audits and ensure staff feedback occur at regular intervals. Analyze and formulate recommendations based on data and maintain utilization management reporting.

Oversight and assistance with documentation, identification, and communication with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination in a timely and cost-effective manner.

JOB QUALIFICATIONS

• Bachelor of Science in Nursing

• 5+ years of work experience in a related job discipline.

• Current, unrestricted Registered Nurse (RN) Ohio licensure

• Must reside within 70 miles of 45229, Cincinnati, OH.

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

Originally posted on Himalayas