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Facility:Work From Home - OhioDepartment:Utilization Review TeamSchedule:Full timeHours:40Job Details:Reporting to the Manager of Utilization Management and in partnership with the Physician Advisor provider team, Revenue Cycle leadership, Integrated Care Management leadership, and the Chief of Quality and Resource Management; supports the development and implementation of a comprehensive denials management program. This role functions as a hospital liaison with external third-party payers to appeal denied claims, research and coordinate completion of patient records required to retrospectively pre certify accounts, and appeal observation, inpatient, medical necessity, and DRG insurance denials. This role functions as an internal liaison for members of the clinical team, clinical and operational leadership in the promotion of best practice processes related to proactive denials management. This role monitors key performance indicators, identifies trends, and recommends areas for documentation and/or process improvement and promotes pro-active documentation compliance for reimbursement. Partners with the Finance and Revenue Cycle Team on appeal process and denials management and prevention. Collaborates with Data Analytics and Integrated Care Leadership to report data and trends for the purpose of education, denials prevention, denials management, and senior leadership reporting. Demonstrates dynamic ability to adapt to ongoing changes within the health insurance industry to effect and implement positive changes for the financial growth of Dayton Children’s Hospital. Recommends and oversees projects as appropriate. In addition to performing the essential functions listed below, may also be assigned other duties as required.

Department Specific Job Details:

Education

+ Completion of accredited BSN program required

Certifications

+ Licensed Registered Nurse in Ohio required

+ Current professional certification in evidence-based care guidelines in use at DCH, currently Milliman Care Guidelines preferred

Experience

+ 5 years of acute care experience in a hospital required

+ 3-5 years as progressive utilization review nurse and knowledge of payers and managed care contracts preferred

+ Previous program management and development experience preferred

Skills

+ Professional skills in a Healthcare setting required

+ Strong teamwork and collaboration required

+ Exceptional customer service and operating technology required

+ Mentoring and Coaching Skills preferred

Education Requirements:

Bachelors: Nursing (Required)

Certification/License Requirements:

[Lic] RN: Registered Nurse (RN) - Ohio Board of Nursing

At Dayton Children's we believe that each moment counts with our patients, families and with each other.

We are moving at a fast pace and are looking for the right talent for our team at Dayton Children's. We want people who embody our values and want to become a part of the Dayton Children's difference. If this is you, apply today!

Our values:

+ Safety--We make safety our first priority.

+ Compassion--We deliver compassionate, family-centered care to all we serve.

+ Ownership--We are the pediatric care experts and act knowing that every patient, visitor and the hospital is our collective responsibility.

+ Collaboration--We work collaboratively to care for children, their families and each other.

+ Innovation--We continuously innovate to make Dayton Children's even better today and into the future.

+ Equity -- We strive for an environment in which all feel welcomed, valued and fairly treated in order to reach their full potential.

Dayton Children’s is proud to be an Equal Opportunity Employer who values diversity and will not discriminate against minorities, women, protected veterans, individuals with disabilities, or on the basis of age, color, gender identity, national origin, race, religion, sex, sexual orientation or transgender status.