Utilization Review Specialist- CSCC U.D.P

Nationwide Children's Hospital

Job Description

Come work for an organization where everything matters.

CONTINGENT role - as needed - 1 or 2 days a week possible

Shift: 8:00am - 4:30pm

The Utilization Review (UR) Specialist Nurse implements and supports the philosophy, mission, values, standards, policies and procedures of Nationwide Childrens Hospital and the Patient Care Services Division. The UR Specialist contributes to the hospitals utilization management plan by applying hospital approved criteria to the clinical review hospitalized patients to determine medical necessity for hospitalization, certification of hospital stay. The UR specialist communicates this information to the health care team and third party payers. The UR specialist assists the Medical Staff and other department leadership in the understanding and implementing the various requirements of the insurance and reimbursement parties. The UR Specialist identifies over and under utilization of resources through medical record review of patient stays. The primary areas of responsibility are: admission and concurrent utilization review, retrospective review, denial management and interaction with staff and departments of the hospital to facilitate appropriate, cost effective patient care.


I. Concurrent Utilization Review
1. Perform admission and continued stay reviews on patients to determine the medical necessity or severity of illness and intensity of service for certification of admission and continued stay. This is done utilizing the approved medical management criteria tool i.e. Interqual and Nationwide Childrens Hospital specific criteria.
2. Reviews documentation to verify appropriate patient status based on standardized criteria or NCH specific criteria.
3. Demonstrates knowledge of growth and development in their application of criteria and using age appropriate medical necessity criteria.
4. Documents medical necessity for inpatient admission and duration of hospitalization. Collaborates with appropriate medical/nursing personnel when medical necessity of in-patient hospitalization is in question.
5. Communicates with the NCH provider when the payer disagrees with patient ordered status or medical necessity of admission or continued stay to determine if denial should be appealed of downgrade accepted.
6. Facilitates appropriate reimbursement by communicating with third party payers, medical/nursing staff and patient/family concerning length of stay, continued stay certification, verification of home care funding and other utilization and reimbursement issues.
7. Participates in the development of guidelines and clinical outcome indicators for given population.
8. Record all required documentation on patient review forms and in computerized systems to maintain a record of the review and the coverage obtained for a patient. Maintain pertinent statistical data as required by the department.
9. Interface with the Patient Access and/or Patient Accounts departments to identify correct insurance, coordination of benefits information, effective dates of coverage, pre/admission notifications/authorizations for certification of inpatient admissions and changes in patient class.
10. Documents appropriately Case Management workflow and in Event Management
11. Interface with other members of the health-care team regarding the implementation of discharge planning and the certification/ justification documentation of patient stays, advising them of external/third party requirements and criteria.
12. Using the case management data, attempts to recognize issues that potentially cause a denial i.e. poor documentation of SI/IS, avoidable days, delayed discharges, etc.
13. Provides education to staff about medical necessity guidelines.

II. Retrospective Review/Denial Management
1. Works closely with respective parties within the organization to facilitate interaction between hospital personnel and payer personnel to overturn potential and/or final denials.
2. Addressed potential denials by pursuing additional documentation and/ or facilitating peer to peer reviews
3. Assists with the retrospective review of records for patients who have insurance changes that impact the authorization of the inpatient encounter.

III. Departmental and Interdepartmental Interactions
1. Maintains knowledge of The Joint Commission, Medicaid, Medicare, and other third-party payer standards and requirements.
2. Assist the UM committee in the reporting of information as set forth in the UM plan, i.e., appropriateness of admissions and continued stay reviews including when known, the over and underutilization of resources.
3. Participates in department and interdepartmental meetings to promote knowledge, troubleshoot, and resolve issues related to utilization management.
4. Serves as an educational and communications resource to Administration, Department heads, physicians and other necessary groups regarding the utilization review/management activity and process.
5. Keep the department manager informed of problems as necessary.
6. Provides assistance with coverage for other members of the department and provides after-hour or holiday coverage as required by the department.
7. Demonstrates accountability in identifying own learning needs and seeking sources of information.



1. Nursing license in the state of Ohio required; RN highly. LPN with demonstrated successful experience in pediatric utilization review considered.
2. Three years of nursing experience, with at least one year in pediatric nursing. This nursing experience may include responsibilities such as Case Management utilization review or discharge planning of a pediatric population.
3. Certification in Case Management or Utilization Management.

1. Possesses excellent written and spoken business communication skills.
2. Has the ability to communicate with health care professionals. Demonstrates diplomacy, tact and a professional demeanor
3. Excellent knowledge of hospitals preferred clinical criteria guidelines.
4. Working knowledge of CMS and other review agency standards.
5. Strong organizational and interpersonal skills.
6. Possesses ability to relate to diverse age and demographic backgrounds. .
7. Computer literate and working knowledge of software applications (word, excel).
8. Ability to efficiently navigate software applications including CM, payer web applications, MITS and others.
9. Effective customer service, communication, and interpersonal skills required for interaction with contacts.


Must be able to see, hear, speak, read, and perform manual tasks with or without accommodation and care for oneself with little or no difficulty.

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 individual 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 his/her supervision.