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UTILIZATION AND APPEALS COORDINATOR Registered Nurse
Norwood, OH
Job Description
| 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 |
TriHealth is an equal opportunity employer. We are committed to fostering a diverse and inclusive workforce.
Job Summary
Company
Start Date
As soon as possible
Employment Term and Type
Regular, Full Time
Required Education
Associate Degree
Required Experience
5 to 7 years
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