Utilization Review RN

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

5d • $63,100 - $94,650 • Remote

About The Position

Ensemble is seeking a remote Utilization Review RN to review hospital admissions and continued stays for medical necessity, support appropriate use of healthcare resources, and help coordinate utilization review and revenue-cycle workflows. The role works with in-house care management, physicians and physician advisors, the Financial Clearance Center, patient access, financial counselors, business offices, payors, and other healthcare team members. Candidates must reside and work within the Mountain Time Zone, hold a current compact RN license or be willing to obtain one, and be able to travel to and work onsite at client, temporary, or corporate locations when business needs require. Access to high-speed internet is required.

The team provides coverage seven days a week between 8:00 a.m. and 10:00 p.m. The schedule is four 10-hour shifts per week, with every other weekend worked on a rotating basis. Available shifts are 10:00 a.m.–8:00 p.m. and 12:00 p.m.–10:00 p.m.; flexibility to work either shift based on business needs is expected. Weekend hours receive a 10% differential, and the 12:00 p.m.–10:00 p.m. shift receives a 10% differential. Eligible hours may receive both differentials. The annual salary range is $63,100–$94,650, depending on experience, education, certifications, and qualifications.

The RN applies approved clinical review criteria to assess medical necessity and patient status, identifies potential over- or under-utilization, coordinates referrals and documentation, and communicates review outcomes. The position also supports denial management, quality and revenue integrity, patient-care facilitation, team communication, and departmental improvement efforts. It requires current clinical competency and knowledge of regulatory and payer requirements, as well as effective collaboration, organization, problem-solving, and customer-service skills.

Requirements

• Bachelor’s degree or equivalent experience in nursing or a related field.
• Current unrestricted RN license required; candidates must have a current compact RN license or be willing to obtain one.
• Candidates must reside and work within the Mountain Time Zone and be authorized to work in the United States.
• Ability to work four 10-hour shifts, including every other weekend, and flexibility to work either of the listed shifts based on business needs.
• Access to high-speed internet for remote work.
• Willingness and ability to travel to and work onsite at client, temporary, or corporate office locations as business needs require.
• Excellent interpersonal, communication, and negotiation skills when interacting with physicians, payors, and healthcare colleagues.
• Commitment to exceptional customer service.
• Ability to communicate effectively verbally and in writing.
• Strong clinical assessment, organizational, and problem-solving skills.
• Ability to identify appropriate internal and community resources and collaborate with healthcare teams, providers, and payors to achieve patient, quality, and financial outcomes.
• Ability to prioritize, organize information, and complete multiple tasks effectively in a fast-paced environment.
• Resourcefulness and ability to work independently.
• Inquisitiveness and openness to innovation, including AI, to explore process improvements and reduce friction for patients and clients.

Nice To Haves

• Compact RN license preferred, although the posting also states candidates may be willing to obtain one.
• Three years of nursing experience in an acute-care environment preferred.
• Utilization review or discharge-planning experience preferred.
• Recent experience with or working knowledge of medical-necessity review criteria preferred.
• Current working knowledge of quality-improvement processes preferred.

Responsibilities

• Use diagnoses, cost criteria, complications, and other proactive triggers to identify potential over- or under-utilization of services.
• Refer cases to a physician advisor in a timely manner when appropriate.
• Identify barriers to patient progress and collaborate with the interdisciplinary team on appropriate use of healthcare resources.
• Coordinate with the Financial Clearance Center, patient access, financial counselors, and business offices on third-party payer billing issues.
• Conduct medical-necessity reviews of admissions, patient status, and continued stays using approved clinical review criteria, potentially from an offsite location.
• Provide inpatient and, when indicated, observation clinical reviews for commercial carriers to the Financial Clearance Center within one business day of admission.
• Communicate review outcomes to in-house care management staff and other relevant parties.
• Work with in-house staff and physicians to clarify information, obtain documentation, identify opportunities, and educate on appropriate levels of care.
• Coordinate the peer-to-peer process with physicians or physician advisors, the Financial Clearance Center, and Revenue Cycle when assigned; maintain documentation relevant to appeals.
• Maintain information to help minimize denials; record denial updates and overturned days, monitor and report denial trends, and monitor readmissions.
• Collaborate with healthcare team members to support management outcomes, including CMS indicators.
• Accurately record statistical data and submit it within required time frames.
• Manage assigned ConnectCare and ADT work queues for revenue-cycle workflow and document work and communications with the Financial Clearance Center, payors, physicians, physician advisors, and in-house care management.
• Send second-level physician reviews as required and document responses and actions.
• Prioritize patient reviews using situational analysis, functional assessment, medical-record review, and clinical review criteria.
• Maintain communication and rapport with in-house care managers and provide care appropriate to the age and needs of patients on the assigned caseload.
• Direct physician and patient communication regarding non-coverage of benefits and maintain professional communication with physicians, nurses, multidisciplinary team members, and administration.
• Educate hospital and medical staff about the utilization review program; respond to voicemail, Skype, email, and Financial Clearance Center communications within required timelines and guidelines.
• Use hospital-provided communication devices during work hours and attend designated meetings or training onsite or online unless prior arrangements are made.
• Collaborate respectfully with peers, share workload, provide backup support, and participate in departmental process-improvement activities.
• Comply with Financial Clearance Center 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, activities, conferences, committees, task forces, and community committees as assigned.
• Perform other job-related duties as required by the supervisor, subject to reasonable accommodation.

Benefits

• Bonus incentives and quarterly and annual incentive programs.
• Shift differentials, including weekend and late-shift differentials.
• Paid professional certifications.
• Tuition reimbursement.
• Comprehensive benefits package, including healthcare, time off, retirement, and well-being programs.
• Career advancement and professional development opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level