Performs pre-certifications, pre-authorizations, re-authorization, concurrent utilization reviews, retrospective reviews, and denial management. Interacts with staff and departments of the hospital ...
Performs pre-certifications, pre-authorizations, re-authorization, concurrent utilization reviews, retrospective reviews, and denial management. Interacts with staff and departments of the hospital ...
Performs pre-certifications, pre-authorizations, re-authorization, concurrent utilization reviews, retrospective reviews, and denial management. Interacts with staff and departments of the hospital ...
Performs pre-certifications, pre-authorizations, re-authorization, concurrent utilization reviews, retrospective reviews, and denial management. Interacts with staff and departments of the hospital ...
Care Review Nurse
Columbus, OH · On-site
Care Review Nurse Works with the Utilization Management team primarily responsible for inpatient ... prior authorizations and/or concurrent review. Assesses services for Members to ensure optimum ...
Care Review Nurse
Columbus, OH · On-site
Care Review Nurse Works with the Utilization Management team primarily responsible for inpatient ... prior authorizations and/or concurrent review. Assesses services for Members to ensure optimum ...
SUMMARY The Utilization Management Specialist is responsible for coordinating and managing all ... Monitors and reviews MCO portals to track authorization status, pending requests, approvals ...
SUMMARY The Utilization Management Specialist is responsible for coordinating and managing all ... Monitors and reviews MCO portals to track authorization status, pending requests, approvals ...
Care Review Nurse
Columbus, OH · On-site
Works with the Utilization Management team primarily responsible for inpatient medical necessity ... prior authorizations and/or concurrent review. Assesses services for Members to ensure optimum ...
Care Review Nurse
Columbus, OH · On-site
Works with the Utilization Management team primarily responsible for inpatient medical necessity ... prior authorizations and/or concurrent review. Assesses services for Members to ensure optimum ...
Utilization Review LVN/RN
Columbus, OH · On-site
Conducts prior authorization reviews to determine financial responsibility Qualifications * 2 years Inpatient background with Hospital Nursing (Med-Surg, ER) * Well versed in Utilization Management ...
Utilization Review LVN/RN
Columbus, OH · On-site
Conducts prior authorization reviews to determine financial responsibility Qualifications * 2 years Inpatient background with Hospital Nursing (Med-Surg, ER) * Well versed in Utilization Management ...
UR Coordinator
$18 - $22/hr
Coordinate initial, concurrent, retrospective, and continued-stay utilization review activities as applicable. * Monitor authorization periods, review dates, and payer deadlines to help prevent gaps ...
New
UR Coordinator
$18 - $22/hr
Coordinate initial, concurrent, retrospective, and continued-stay utilization review activities as applicable. * Monitor authorization periods, review dates, and payer deadlines to help prevent gaps ...
New
UR Coordinator, Full Time
$24 - $32/hr
About the Role RiverVista is seeking a detail-oriented and knowledgeable Utilization Review (UR) Coordinator to support clinical documentation, insurance authorization processes, and regulatory ...
UR Coordinator, Full Time
$24 - $32/hr
About the Role RiverVista is seeking a detail-oriented and knowledgeable Utilization Review (UR) Coordinator to support clinical documentation, insurance authorization processes, and regulatory ...
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. How you will make an impact: * Managing incoming calls or ...
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. How you will make an impact: * Managing incoming calls or ...
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. How you will make an impact: * Managing incoming calls or ...
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. How you will make an impact: * Managing incoming calls or ...
The Transplant Nurse, Utilization Review provides the highest level of clinical service both ... authorization database. Facilitate discharge planning process during concurrent review and post ...
New
The Transplant Nurse, Utilization Review provides the highest level of clinical service both ... authorization database. Facilitate discharge planning process during concurrent review and post ...
New
Utilization Management Rep I
Mason, OH · On-site
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. How you will make an impact: * Managing incoming calls or ...
Utilization Management Rep I
Mason, OH · On-site
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. How you will make an impact: * Managing incoming calls or ...
The Transplant Nurse, Utilization Review provides the highest level of clinical service both ... authorization database. Facilitate discharge planning process during concurrent review and post ...
New
The Transplant Nurse, Utilization Review provides the highest level of clinical service both ... authorization database. Facilitate discharge planning process during concurrent review and post ...
New
The Transplant Nurse, Utilization Review provides the highest level of clinical service both ... authorization database. Facilitate discharge planning process during concurrent review and post ...
New
The Transplant Nurse, Utilization Review provides the highest level of clinical service both ... authorization database. Facilitate discharge planning process during concurrent review and post ...
New
The Transplant Nurse, Utilization Review provides the highest level of clinical service both ... authorization database. Facilitate discharge planning process during concurrent review and post ...
New
Quick apply
The Transplant Nurse, Utilization Review provides the highest level of clinical service both ... authorization database. Facilitate discharge planning process during concurrent review and post ...
New
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. How you will make an impact: * Managing incoming calls or ...
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. How you will make an impact: * Managing incoming calls or ...
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. How you will make an impact: * Managing incoming calls or ...
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. How you will make an impact: * Managing incoming calls or ...
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. ??How you will make an impact: * Managing incoming calls or ...
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. ??How you will make an impact: * Managing incoming calls or ...
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. How you will make an impact: * Managing incoming calls or ...
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. How you will make an impact: * Managing incoming calls or ...
Utilization Management Rep I
Mason, OH · On-site
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. ??How you will make an impact: * Managing incoming calls or ...
Utilization Management Rep I
Mason, OH · On-site
The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. ??How you will make an impact: * Managing incoming calls or ...
Authorization Utilization Review information
What is authorization utilization review?
Authorization Utilization Review is a process used by healthcare organizations and insurance companies to assess the medical necessity and appropriateness of medical services before they are provided. The main goal is to ensure that patients receive care that is effective, efficient, and covered by their health plan. This review typically involves evaluating patient records, treatment plans, and provider requests to decide if the requested services meet established guidelines. By doing so, it helps control healthcare costs and ensures quality care for patients.
What are the key skills and qualifications needed to thrive as an authorization utilization review specialist?
To thrive as an Authorization Utilization Review Specialist, you need a solid understanding of medical terminology, healthcare regulations, and insurance policies, often backed by a clinical background or relevant certifications. Familiarity with utilization management software, electronic health records (EHR), and payer portals is typically required. Strong attention to detail, analytical thinking, and effective communication are vital soft skills for coordinating with providers and payers. These skills ensure accurate authorization decisions, regulatory compliance, and efficient patient care coordination.
What are some common challenges faced by professionals in authorization utilization review roles, and how can they be addressed?
Professionals in Authorization Utilization Review often encounter challenges such as managing high caseloads, navigating complex insurance guidelines, and ensuring timely communication with providers and patients. Staying organized and up-to-date with evolving payer requirements is essential to avoid delays or denials. Building strong collaboration with clinical teams and leveraging electronic health record systems can help streamline workflows and improve efficiency in the review process.
What is the difference between Authorization Utilization Review vs Claims Reviewer?
| Aspect | Authorization Utilization Review | Claims Reviewer |
|---|---|---|
| Credentials | Typically requires healthcare or insurance-related certifications, such as RN, CPC, or licensed healthcare professionals | Often requires similar credentials, focusing on insurance policies and claims processing |
| Work Environment | Hospitals, insurance companies, healthcare facilities | Insurance companies, third-party administrators, healthcare organizations |
| Industry Usage | Used to assess medical necessity before approving services | Used to evaluate claims for payment accuracy and compliance |
Authorization Utilization Review and Claims Reviewer roles both involve insurance and healthcare knowledge, but Authorization Utilization Review focuses on pre-authorization of services, while Claims Review centers on post-service claims assessment. Understanding these differences helps clarify career paths and job expectations in healthcare insurance.
What are popular job titles related to Authorization Utilization Review jobs in Ohio?
For Authorization Utilization Review jobs in Ohio, the most frequently searched job titles are:
- Remote Medical Record Review Nurse
- Remote Utilization Review Rn
- Remote Utilization Review Social Worker
- Flex Schedule Remote Utilization Review Nurse
- Evening Utilization Review Nurse
- Night Utilization Review Nurse
- Appeals Nurse
- Optum Clinical Claim Review Nurse
- No Experience Utilization Management Nurse
- No Experience Utilization Review Nurse
What job categories do people searching Authorization Utilization Review jobs in Ohio look for?
The top searched job categories for Authorization Utilization Review jobs in Ohio are:
- Case Manager Utilization Review Nurse
- Fulltime Cigna Utilization Review Nurse
- Weekend Utilization Review
- Per Diem Chart Review Nurse Practitioner
- Utilization Review Coordinator Remote
- Remote Utilization Review Nurse Practitioner
- Insurance Utilization Review
- Remote Lpn Utilization Review
- Remote Dental Utilization Review
- Per Diem Remote Occupational Therapy Utilization Review
What cities in Ohio are hiring for Authorization Utilization Review jobs?
Cities in Ohio with the most Authorization Utilization Review job openings:
Full-time
Re-posted 8 days ago
Nationwide Children's Hospital rating
6.9
Based on 131 frontline employees who took The Breakroom Quiz
552nd of 1,064 rated hospitals
Job description
Overview:
Schedule: Monday-Friday (8:00am-4:30pm)
Position is work from home after a 90 day in-office training period.
Job Description Summary:
Reviews behavioral health cases to determine medical necessity and appropriateness of care, ensuring compliance with established guidelines and policies. Performs pre-certifications, pre-authorizations, re-authorization, concurrent utilization reviews, retrospective reviews, and denial management. Interacts with staff and departments of the hospital to facilitate appropriate, cost-effective patient care.
Job Description:
Essential Functions:
Education Requirement:
Bachelor's Degree in Social Work, Psychology, or related field, required.
Licensure Requirement:
(not specified)
Certifications:
(not specified)
Skills:
Experience:
Physical Requirements:
OCCASIONALLY: Bend/twist, Climb stairs/ladder, Flexing/extending of neck, Lifting / Carrying: 0-10 lbs, Reaching above shoulder, Squat/kneel
FREQUENTLY: Standing, Walking
CONTINUOUSLY: Audible speech, Color vision, Computer skills, Decision Making, Depth perception, Hand use: grasping, gripping, turning, Hearing acuity, Interpreting Data, Peripheral vision, Problem solving, Repetitive hand/arm use, Seeing - Far/near, Sitting
Additional Physical Requirements performed but not listed above:
(not specified)
"The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the individuals so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under their supervision. EOE M/F/Disability/Vet"
Schedule: Monday-Friday (8:00am-4:30pm)
Position is work from home after a 90 day in-office training period.
Job Description Summary:
Reviews behavioral health cases to determine medical necessity and appropriateness of care, ensuring compliance with established guidelines and policies. Performs pre-certifications, pre-authorizations, re-authorization, concurrent utilization reviews, retrospective reviews, and denial management. Interacts with staff and departments of the hospital to facilitate appropriate, cost-effective patient care.
Job Description:
Essential Functions:
- Conducts utilization reviews of behavioral health cases to determine medical necessity, appropriateness of care, and adherence to clinical guidelines.
- Communicates with healthcare teams and third-party payors to ensure the delivery of quality care and optimum payment.
- Assists with retrospective reviews and denial management to maintain appropriate and cost-effective patient care.
- Documents all case reviews and maintains accurate records of all clinical activities and coverage information.
- Provides education and support regarding utilization review and management activities and processes.
- Analyzes clinical data to identify trends and patterns that may impact patient care. Participates in quality improvement initiatives to enhance the overall delivery of behavioral health services.
- Facilitates reimbursement by communicating with payers, other staff, patients, and families concerning status of funding and required actions.
Education Requirement:
Bachelor's Degree in Social Work, Psychology, or related field, required.
Licensure Requirement:
(not specified)
Certifications:
(not specified)
Skills:
- Excellent written and verbal communication and interpersonal skills.
- Excellent customer service and organizational skills.
- Working knowledge of CMS and other review agency standards.
- Proficient with software applications including CM, payer web applications, MITS, and others.
Experience:
- Three years of behavioral health experience, required.
- One year of experience in pediatric care or services, required.
- Utilization review or utilization management experience, preferred.
Physical Requirements:
OCCASIONALLY: Bend/twist, Climb stairs/ladder, Flexing/extending of neck, Lifting / Carrying: 0-10 lbs, Reaching above shoulder, Squat/kneel
FREQUENTLY: Standing, Walking
CONTINUOUSLY: Audible speech, Color vision, Computer skills, Decision Making, Depth perception, Hand use: grasping, gripping, turning, Hearing acuity, Interpreting Data, Peripheral vision, Problem solving, Repetitive hand/arm use, Seeing - Far/near, Sitting
Additional Physical Requirements performed but not listed above:
(not specified)
"The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the individuals so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under their supervision. EOE M/F/Disability/Vet"
What Nationwide Children's Hospital employees say
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Benefits
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Workplace
Get the full story on Breakroom
About Nationwide Children's Hospital
Sourced by ZipRecruiter
Nationwide Children's Hospital, established in 1894, is a leading pediatric healthcare system based in Columbus, Ohio, United States. They serve as a primary pediatric network, providing wellness, preventive, diagnostic, treatment, and rehabilitative care for infants, children, adolescents, and adults with congenital disease. Being the third-largest pediatric hospital in the nation, Nationwide Children's Hospital prides itself on its relentless commitment to children and their families, driven by their core values of respect, integrity, determination, empathy, and solidarity. The institution's comprehensive mission is to enhance the health of children by providing high-quality, family-centered care, conducting groundbreaking research, advocating for pediatric health, and training top healthcare professionals.
Industry
Hospitals
Company size
10,000+ Employees
Headquarters location
Columbus, OH, US
Year founded
1892