Kettering Health is a not-for-profit system of 13 medical centers and more than 120 outpatient facilities serving southwest Ohio. We are committed to transforming the health care experience with high-quality care for every stage of life. Our service-oriented mission is in action every day, whether it’s by providing care in our facilities, training the next generation of health care professionals, or serving others through international outreach.

Kettering Health Hamilton

• Kettering Health Hamilton, formerly Fort Hamilton Hospital, has been serving the Hamilton community for over 90 years.
• Leads the way to better health in the Butler County area, serving patients from Fairfield, Oxford, Cincinnati, Middletown and surrounding communities.
• KH Hamilton offerings include maternity, emergency, the most advanced wound healing in Butler County, and a range of outpatient services. 
• In 2020, KH Hamilton received an “A” from the Leapfrog Group, a national patient safety watchdog, ranking among the safest hospitals in the United States.
• Full-service, community hospital licensed for 203 beds. 
• In 2020, KH Hamilton received several awards from Healthgrades:
  • America’s 250 Best Hospitals (2018-2020)
  • America’s 100 Best Pulmonary Care (2018-2020)
  • Gastrointestinal Care Excellence Award (2020)

Job Summary 

• The Utilization Management Specialist will perform utilization review functions for KHN hospitals.
• Review inpatient and observation admissions to ensure correct assignment of Admission status. Communicates concurrently and resolves medical necessity discrepancies with physicians and other hospital leadership as needed.  
• Responsible for completing clinical review on all assigned patients and communicating the reviews on a timely basis to payors.
• Obtain authorizations in a timely manner for all patients/payors as assigned.
• Responsible for communicating and collaborating with all necessary parties (Physician Advisors, Care Coordination, Patient Financial Services, payors etc.) and documenting all pertinent information in a timely manner within required hospital systems
• Knowledge and application of federal, state, HFAP and Quality improvement regulations
• Use KHN common screening tool (Indicia/Milliman) for as clinical criteria
• Track, trend and report payor specific issues.
• Identify potential or actual denials for admission or ongoing stay both during the patient’s hospital stay and post-discharge.
• Review and decide the validity of medical necessity payer denials in collaboration with Physician Advisors.
• Submit payer denial appeals based on contact with payers and research.
• Participate in design of workflows and procedures to reduce incidence of denials.
• Participate in Payer escalation and Administrative Law Judge hearings as needed to pursue reversal of denials, as needed. Education Requirements

Educational Requirements

• Graduate of accredited RN nursing program with a current unrestricted license to practice in Ohio
• BSN from an accredited school or Healthcare related BS required, Master’s degree preferred

Skills/Others

• Requires/preferred two years’ experience in utilization management, case management, care coordination, clinical outcomes and/or clinical documentation improvement.
• Five years clinical experience minimum, Critical care or ED experience preferred.
• Knowledge of Milliman Care Guidelines, as well as knowledge of third-party payer regulations related to utilization and quality review preferred. MCG Certification required within one year of hire to department.
• Case Management certification preferred. ACM or equivalent certification required within two years of hire.
• Knowledge and application of federal, state, HFAP and Quality improvement regulations
• Requires critical thinking skills, decisive judgement and the ability to work with minimal supervision in a multidisciplinary setting.
• Must successfully self-direct daily workflow and identify priority tasks.
• Ability to clearly communicate with and establish and maintain good rapport with physicians, clinicians and other related stakeholders including other health team members and hospital and network leaders.
• Ability to accept responsibility, analyzes problems, evaluate reports, and make decisions and recommendations required.
• Experience working with process improvement principles
• Demonstrates flexibility with a willingness to learn and adapt to changes in regulations and task-related priorities.
• Actively participates in meetings.
• Experience with computers required. Experience with Microsoft applications and EPIC software preferred.
• Proficient typing skills.

Must be flexible and able to manage job functions despite shifting priorities.