Utilization and Appeals Coordinator

Utilization and Appeals Coordinator

Employer:

Tri Health

Location:

Cincinnati, OH

Salary: $120,286 - $130,286

This position may perform utilization management functions on a prospective, concurrent or retrospective basis in order to maximize revenue for Tri Health. 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.

• 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

• Teamwork, communication, problem solving, conflict resolution.
• Risk management
• Assess and analyze quality indicators, document them, and differentiate between morbidity and mortality outcomes. Reports as indicated to manager, medical director.
• Identify areas for self‑improvement, maintain areas of current practice, support organizational activities.
• Apply the principles of UR in processes of admission orders, levels of care, document current status, communicate with attending physicians.

• 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.