Oncology prior authorization * Utilization management * Medical necessity review * Oncology reimbursement * Revenue cycle operations * Strong understanding of: * Oncology treatment regimens * Medical ...
Oncology prior authorization * Utilization management * Medical necessity review * Oncology reimbursement * Revenue cycle operations * Strong understanding of: * Oncology treatment regimens * Medical ...
Oncology prior authorization * Utilization management * Medical necessity review * Oncology reimbursement * Revenue cycle operations * Strong understanding of: * Oncology treatment regimens * Medical ...
Oncology prior authorization * Utilization management * Medical necessity review * Oncology reimbursement * Revenue cycle operations * Strong understanding of: * Oncology treatment regimens * Medical ...
Utilization Management RN
Columbus, OH · On-site
Clinical Review: · Conduct comprehensive clinical reviews of prior authorization requests to ... Previous experience in utilization management * Comprehensive knowledge of Microsoft Word, Outlook ...
Utilization Management RN
Columbus, OH · On-site
Clinical Review: · Conduct comprehensive clinical reviews of prior authorization requests to ... Previous experience in utilization management * Comprehensive knowledge of Microsoft Word, Outlook ...
Care Review Clinician
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 Clinician
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 ...
UR Manager
Columbus, OH · On-site
For billing and hospitalization utilization review purposes, the reviewer will identify and certify the acute hospitallength of stay authorized for each case. Initiate and maintain medical records ...
UR Manager
Columbus, OH · On-site
For billing and hospitalization utilization review purposes, the reviewer will identify and certify the acute hospitallength of stay authorized for each case. Initiate and maintain medical records ...
Building case prior authorization requests for members. Heavy data entry and making phone calls out ... or utilization review for other healthcare services. Checks eligibility and verifies benefits ...
Building case prior authorization requests for members. Heavy data entry and making phone calls out ... or utilization review for other healthcare services. Checks eligibility and verifies benefits ...
RN Case Manager - Prior Authorization
Columbus, OH · On-site
$30/hr
Utilization review, prior authorization, or managed care experience preferred. * Active OH RN Licensure * Experienced with either Interqual or Milliman Licenses/Certifications: Current RN, required.
RN Case Manager - Prior Authorization
Columbus, OH · On-site
$30/hr
Utilization review, prior authorization, or managed care experience preferred. * Active OH RN Licensure * Experienced with either Interqual or Milliman Licenses/Certifications: Current RN, required.
Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization ... Resolves escalated complaints regarding utilization management and long-term services and supports ...
New
Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization ... Resolves escalated complaints regarding utilization management and long-term services and supports ...
New
Medical Review Nurse (RN)
Columbus, OH · On-site
$29.05 - $56.64/hr
Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization ... utilization management and long-term services and supports (LTSS) issues. • Identifies and ...
New
Medical Review Nurse (RN)
Columbus, OH · On-site
$29.05 - $56.64/hr
Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization ... utilization management and long-term services and supports (LTSS) issues. • Identifies and ...
New
The Prior Authorization Review Nurse works closely with healthcare providers, interdisciplinary ... Certification in Case Management (CCM) or Utilization Review (UR). * Experience with Medicaid and ...
The Prior Authorization Review Nurse works closely with healthcare providers, interdisciplinary ... Certification in Case Management (CCM) or Utilization Review (UR). * Experience with Medicaid and ...
Prior Authorization Specialist
Hamilton, OH · On-site
$16.75 - $22.25/hr
... review requests when required by the payer. * Monitors authorization expiration dates, visit limits, and service utilization to ensure continued coverage when applicable. * Maintains current ...
Prior Authorization Specialist
Hamilton, OH · On-site
$16.75 - $22.25/hr
... review requests when required by the payer. * Monitors authorization expiration dates, visit limits, and service utilization to ensure continued coverage when applicable. * Maintains current ...
Sr. Physician Services Specialist, Ortho, Full Time, First Shift
West Chester, OH · On-site
$17 - $22.75/hr
Coordinates with utilization review for authorization status to avoid financial risk Updates documentation in referral tab with all authorization updates Manage and audit assigned referral and ...
Sr. Physician Services Specialist, Ortho, Full Time, First Shift
West Chester, OH · On-site
$17 - $22.75/hr
Coordinates with utilization review for authorization status to avoid financial risk Updates documentation in referral tab with all authorization updates Manage and audit assigned referral and ...
We are currently seeking Clinical Services Utilization Supervisor to join our Ohio Home Care ... reviews prior authorizations prior to submissions to state specific Department of Medicaid for ...
We are currently seeking Clinical Services Utilization Supervisor to join our Ohio Home Care ... reviews prior authorizations prior to submissions to state specific Department of Medicaid for ...
Duties: * Build waiver authorizations for members on Medicaid and Medicare. * Providing ... utilization review for other healthcare services * Checks eligibility and verifies benefits ...
Duties: * Build waiver authorizations for members on Medicaid and Medicare. * Providing ... utilization review for other healthcare services * Checks eligibility and verifies benefits ...
... review process including leading clinical meetings to facilitate relationship building and ... Demonstrated success with improving achieving productivity for authorization requests. * Strong ...
... review process including leading clinical meetings to facilitate relationship building and ... Demonstrated success with improving achieving productivity for authorization requests. * Strong ...
Oncology prior authorization * Utilization management * Medical necessity review * Oncology reimbursement * Revenue cycle operations * Strong understanding of: * Oncology treatment regimens * Medical ...
Oncology prior authorization * Utilization management * Medical necessity review * Oncology reimbursement * Revenue cycle operations * Strong understanding of: * Oncology treatment regimens * Medical ...
Homecare Prior Authorization Supervisor
Columbus, OH · On-site
$16.75 - $23/hr
One year of medical terminology, public relations, quality improvement, and utilization review experience, required. * One year leadership or management experience, preferred. Physical Requirements:
Homecare Prior Authorization Supervisor
Columbus, OH · On-site
$16.75 - $23/hr
One year of medical terminology, public relations, quality improvement, and utilization review experience, required. * One year leadership or management experience, preferred. Physical Requirements:
Homecare Prior Authorization Supervisor
Columbus, OH · Hybrid
$16.75 - $23/hr
One year of medical terminology, public relations, quality improvement, and utilization review experience, required. * One year leadership or management experience, preferred. Physical Requirements:
Homecare Prior Authorization Supervisor
Columbus, OH · Hybrid
$16.75 - $23/hr
One year of medical terminology, public relations, quality improvement, and utilization review experience, required. * One year leadership or management experience, preferred. Physical Requirements:
Homecare Prior Authorization Supervisor
Columbus, OH · On-site
$16 - $22.25/hr
One year of medical terminology, public relations, quality improvement, and utilization review experience, required. * One year leadership or management experience, required. Physical Requirements:
Homecare Prior Authorization Supervisor
Columbus, OH · On-site
$16 - $22.25/hr
One year of medical terminology, public relations, quality improvement, and utilization review experience, required. * One year leadership or management experience, required. Physical Requirements:
Client Insurance Specialist
$20.97 - $24.56/hr
Collaborate with utilization review, prior authorization, and billing staff to resolve client insurance issues and minimize service interruptions * Utilize data tracking and analytics to identify ...
Quick apply
Client Insurance Specialist
$20.97 - $24.56/hr
Collaborate with utilization review, prior authorization, and billing staff to resolve client insurance issues and minimize service interruptions * Utilize data tracking and analytics to identify ...
Authorization Utilization Review information
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 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 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:
- Behavioral Health Utilization Review
- Remote Medical Record Review Nurse
- Remote Utilization Review Rn
- No Experience Utilization Management Nurse
- No Experience Utilization Review Nurse
- Appeals Nurse Remote
- Night Utilization Review Nurse
- Per Diem Utilization Review Nurse
- Utilization Management
- No Experience Hedis 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:
- Dental Utilization Review
- Remote Preservice Review Nurse
- Utilization Review Case Manager
- Work From Home Utilization Review
- Pt Ot Utilization Review
- Chart Utilization Review
- Flexible Cigna Utilization Review Nurse
- Per Diem Remote Occupational Therapy Utilization Review
- Medical Claims Review Nurse
- Utilization Review Coordinator Remote
What cities in Ohio are hiring for Authorization Utilization Review jobs? Cities in Ohio with the most Authorization Utilization Review job openings:
Full-time
Posted 16 days ago
Southwest General Health Center rating
6.9
Based on 46 frontline employees who took The Breakroom Quiz
551st of 1,055 rated hospitals
Job description
Southwest General Health Center is a 352-bed community hospital located in Middleburg Heights, Ohio. One of the last standing community hospitals in Northeast Ohio, we partner with University Hospitals and other local community organizations to provide a full range of services to all who need us. We are certified as a Level III Trauma Center and a Primary Stroke Center, and have been serving our community for over 100 years!
At Southwest General, we believe in the power of teamwork, creating a family-like environment, ensuring a work-life balance, and providing meaningful work to make a real difference in people’s lives.
We value our employees as much as our patients, offering a supportive work culture that encourages growth, development and collaboration. We’re committed to building a team that works together, supports each other, and ultimately, saves lives every day.
At Southwest, you are family.
Position summary:
The Revenue Integrity Specialist is responsible for facilitating proper charge capture, billing and adjudication of claims in accordance with standard Billing policies and reimbursement principles, clinical documentation practices and CPT/HCPCS and ICD-10CM coding through the use of the hospital’s electronic information systems and manual processes. This position will be responsible for ensuring that all billing charges are captured in an appropriate manner for the Hospital’s oncology services, specifically focusing on infusion, injection, targeted therapies, diagnostic testing and radiation therapy treatments.
This person will identify, analyze and reconcile billing errors or omissions while ensuring timely verification, authorization, and documentation of insurance requirements for oncology and infusion services. This position serves as a key liaison between providers, patients, payers, and revenue cycle teams to ensure compliance with medical necessity criteria, payer policies, and regulatory requirements while minimizing treatment delays and denials.
The specialist proactively reviews treatment plans against payer guidelines, support authorizations, manages appeals, and supports financial stewardship of the cancer center through accurate and compliant reimbursement practices. This person must be familiar with standard concepts, practices, and procedures in healthcare. The applicant will be responsible to perform a variety of tasks as assigned and will work under general supervision of the Revenue Integrity and Cancer Center Leadership.
MINIMUM QUALIFICATIONS
Education: Associate degree required, bachelor’s degree preferred. Equivalent combination of education and healthcare experience may be considered.
Required length and type of experience:
- Experience with Medicare, Medicaid, and commercial insurance plans.
- Experience working in a cancer center, oncology practice, infusion center, or hospital oncology department preferred.
- Minimum 3–5 years of experience in:
- Oncology prior authorization
- Utilization management
- Medical necessity review
- Oncology reimbursement
- Revenue cycle operations
- Strong understanding of:
- Oncology treatment regimens
- Medical necessity standards
- Prior authorization processes
- Payer reimbursement methodologies
- Clinical documentation requirements
- Insurance benefit structures
Required licensure, certification or registry: Certified Coding Specialist (CCS) preferred and/or Utilization Review or Case Management certification preferred
What Southwest General Health Center employees say
Pay
Benefits
Hours and flexibility
Workplace
Get the full story on Breakroom
About Southwest General
Sourced by ZipRecruiter
Industry
Hospitals
Company size
1,001 - 5,000 Employees
Headquarters location
Middleburg Heights, OH, US
Year founded
1920