Lead Utilization Review, RN

Ensemble Health Partners • Work at Home - Ohio - Other, OH

2d • $39 - $53 • Remote

About The Position

The Lead Utilization Review RN contributes to the organization’s financial, quality, and clinical performance by supporting an outcomes-oriented patient-care delivery system. The role helps improve the quality and completeness of medical-record documentation through collaboration with physicians, nurses, other caregivers, coding professionals, hospital liaisons, and revenue-cycle teams. The Lead UR RN monitors and evaluates care to ensure services are medically necessary, provided in the appropriate setting, and consistent with governmental and regulatory standards.

Responsibilities include utilization review, medical-necessity determinations, denial and appeal coordination, discharge-planning referrals, quality and revenue-integrity activities, patient-care facilitation, communication, and teamwork. The position also maintains knowledge of clinical and payer requirements, documents review and communication activity, and participates in departmental and hospital activities.

The UR department operates seven days per week from 8:00 a.m. to 10:00 p.m. Candidates must be willing and able to work within those scheduled hours, including weekends as needed. The posting includes a pay scale of $39.40 to $53 per hour, based on experience. The position is limited to individuals who reside and are authorized to work in the United States.

Requirements

• Current unrestricted RN license.
• At least five years of nursing experience in an acute-care environment.
• Experience in utilization review and discharge planning.
• Ability to communicate ideas and thoughts effectively, verbally and in writing.
• Ability to collaborate with all members of the care team.
• Strong clinical assessment, organization, and problem-solving skills.
• Ability to assess and identify appropriate internal and community resources for an assigned caseload and work collaboratively with healthcare-team members, providers, and payors to achieve patient, quality, and financial outcomes.
• Ability to organize information quickly and effectively, prioritize, and complete multiple tasks effectively.
• Strong technical skills, including database and spreadsheet analysis.
• Associate degree in Nursing required.

Nice To Haves

• Recent, working knowledge of medical-necessity review criteria experience.
• Bachelor’s degree in Nursing preferred.

Responsibilities

• Use proactive triggers, including diagnoses, cost criteria, and complications, to identify potential over- or under-utilization of services and refer cases to a physician advisor in a timely manner.
• Identify barriers to patient progress, collaborate with the hospital liaison, and coordinate with financial clearance, patient access, financial counselors, and business-office staff on third-party payer billing issues.
• Conduct daily medical-necessity reviews of admissions using approved clinical review criteria, including patient-status and continued-stay reviews; reviews may be conducted from an offsite location.
• Provide inpatient and, when indicated, observation clinical reviews to commercial carriers within one business day of admission.
• Communicate medical-necessity review outcomes to the hospital liaison; clarify information, obtain documentation, present opportunities, and provide education about the appropriate level of care.
• Coordinate the appeal process with the liaison and relevant financial-clearance and revenue-cycle teams when assigned; maintain appeal documentation, record denial updates and overturned days, monitor and report denial trends, and report potential and current readmissions to the liaison.
• Evaluate medical records for discharge-planning needs and make timely referrals to the care team or liaison to support timely discharge and connection with post-discharge care providers.
• Collaborate with the healthcare team to achieve outcomes-management goals, including CMS indicators; accurately record and submit statistical data within required time frames.
• Manage assigned ConnectCare and ADT work queues for case-management revenue-cycle workflow and document work and communications involving the Financial Clearance Center and hospital-based liaison.
• Send second-level physician reviews as required and document responses and actions.
• Prioritize patient-care needs based on situational analysis, functional assessment, medical-record review, and clinical review criteria.
• Collaborate with the liaison to develop and expand the plan of care, monitor and evaluate it, identify variances, make adjustments, and direct care toward predictable outcomes.
• Provide care appropriate to the age and needs of patients served, applying knowledge of lifespan growth and development and interpreting patient-status information in accordance with departmental policies and procedures.
• Direct physician and patient communication about non-coverage of benefits to the liaison; maintain professional communication with physicians, nurses, multidisciplinary team members, liaisons, and administration.
• Educate hospital and medical staff about the case-management program; respond to voicemail in a timely manner and use hospital-provided communication devices during work hours.
• Remain available for designated meetings or training unless prior arrangements are made, and maintain a calm, professional demeanor during conflict or crisis.
• Collaborate respectfully with peers, communicate clearly and promptly, share workload, provide backup support, and participate in departmental process-improvement activities.
• Comply with hospital and department policies and procedures, including confidentiality and patient rights; maintain clinical competency and current knowledge of regulatory and payer requirements, including medical-necessity criteria, MS-DRGs, and POA.
• Participate in departmental meetings and activities and in hospital or community committees, conferences, and task forces as assigned; perform other duties as assigned.

Benefits

• Bonus incentives and quarterly and annual incentive programs.
• Paid professional certifications; each associate can earn a certification relevant to their field.
• Tuition reimbursement.
• Comprehensive benefits package, including healthcare, time off, retirement, and well-being programs.
• Professional development and career advancement opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree