Utilization Registered Nurse

Join Our Team as a Utilization Nurse!

At TriHealth, we are driven by a shared commitment to excellence and innovation in healthcare. We believe that every test, analysis, and result plays a vital role in our mission to provide the highest standard of care to our patients.

Join us in our mission to advance healthcare and improve lives. Apply today and be part of a team that is passionate about making a difference.

We offer career growth opportunities, and a comprehensive benefits package.

Location:

• Remote

Work Schedule:

• Full - Time (80 hours bi-weekly)
• Day shift

Incentives & Benefits:

We offer a comprehensive benefits package, including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement.

https://careers.trihealth.com/what-we-offer/benefits

Job Requirements:

Associate's Degree - Nursing (Required)

New hires required to obtain BSN within 5 years of hire (Required)

3 - 4 years of clinical experience in nursing. (Required)

Specialty Patient Care Guidelines

Basic computer skills

Problem solving

Establish effective working relationship with members of healthcare team and external customers

Prior experience in self-directed position

Registered Nurse Upon Hire Required

Membership in related professional organization. Preferred

Job Overview:

This position reports to the supervisor or manager of Utilization Management. The Utilization Management (UM) Nurse is responsible for evaluation of medical necessity to ensure care is delivered at the appropriate level, and aligns with regulatory and payer requirements. The UM Nurse collaborates with physicians, care management and payers to ensure authorization of provided services.

All candidates for this position should have knowledge of computer programs such as Microsoft Outlook, Microsoft Word, TEAMS, EPIC, and Voalte. Working autonomously is necessary so it is essential that time management and self discipline be strong characteristics of candidates for this role.

Job Responsibilities

• Performs initial and concurrent reviews to determine medical necessity using evidenced based criteria.
• Validates the appropriate patient class (inpatient, observation, bedded outpatient) based on CMS regulations, payer requirements and department protocol.
• Provides initial and concurrent clinical information to payers timely based on individual payer requirements.
• Follows up with payers as needed to ensure authorization is obtained.
• Coordinates with interdisciplinary care team, including attending physicians, physician advisors and care management.
• Recognizes and documents delays in care; escalates as appropriate.

Working Conditions

Bending - Rarely

Climbing - Rarely

Concentrating - Consistently

Continuous Learning - Consistently

Hearing: Conversation - Consistently

Hearing: Other Sounds - Consistently

Interpersonal Communication - Consistently

Kneeling - Rarely

Lifting <10 Lbs. - Frequently

Lifting 50+ Lbs. - Rarely

Lifting <50 Lbs. - Rarely

Pulling - Rarely

Pushing - Rarely

Reaching - Frequently

Reading - Consistently

Sitting - Consistently

Standing - Occasionally

Stooping - Rarely

Talking - Consistently

Thinking/Reasoning - Consistently

Use of Hands - Consistently

Color Vision - Frequently

Visual Acuity: Far - Occasionally

Visual Acuity: Near - Frequently

Walking - Occasionally

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

KeyWords: Registered Nurse, Utilization