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 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
• 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.

• Climbing - Rarely
• Concentrating - Consistently
• Continous Learning - Consistently
• Hearing:
  Conversation - Consistently
• Hearing:
  Other Sounds - Consistently
• Interpersonal Communication - Consistently
• Kneeling - Occasionally
• Lifting