Utilization Review RN - Denials

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

1d • $63,100 - $94,650 • Remote

About The Position

Ensemble is seeking a remote Utilization Review Specialist with at least one year of denial management experience. The role reviews medical necessity, utilization of healthcare resources, patient status and continued stays, and works with in-house care management, physicians, the Financial Clearance Center, patient access, financial counselors, business offices, and revenue cycle teams. The position requires a current compact RN license or willingness to obtain one. The schedule is Monday through Friday, 8:30 a.m. to 5:00 p.m., with occasional weekend coverage. Although remote, the role requires high-speed internet and willingness and ability to travel to and work onsite at client, temporary, or corporate offices when business needs require.

The position supports revenue integrity and quality by managing payer reviews and denials, maintaining accurate documentation and data, monitoring denial trends and readmissions, and supporting workflow queues. It also facilitates patient care through review prioritization, interdisciplinary collaboration, and communication with physicians, patients, and hospital staff. The employee is expected to maintain clinical and regulatory knowledge, participate in process improvement and departmental activities, and provide backup support as needed.

The posted salary range is $63,100–$94,650 annually, dependent on experience, education, certifications, and overall qualifications. The opportunity includes bonus incentives, shift differentials, paid certifications, tuition reimbursement, comprehensive benefits, and career advancement.

Requirements

• Bachelor’s degree or equivalent experience in nursing or a related field.
• Current unrestricted RN license required; current compact RN license required or willingness to obtain one.
• At least 5 years of acute care clinical experience.
• At least 2 years of utilization review experience.
• At least 1 year of denial management experience.
• Demonstrated proficiency with both InterQual and MCG criteria.
• Required experience with Epic EMR.
• Strong critical thinking and clinical judgment, with the ability to work independently.
• Excellent written and verbal communication skills.
• Strong technical aptitude and ability to learn, adapt to, and use healthcare technologies and software applications.
• Ability to manage multiple priorities, stay organized, and meet deadlines in a fast-paced environment.
• Strong time management and workload prioritization skills.
• Ability to collaborate effectively within a multidisciplinary team while remaining accountable for individual responsibilities.
• Strong understanding of CMS guidelines and their application to clinical review processes.
• Inquisitiveness and openness to innovation, including AI, to improve processes and patient and client experiences.
• Access to high-speed internet for remote work.
• Willingness and ability to travel to and work onsite at client, temporary, or corporate locations as business needs require.
• Must reside and be authorized to work in the United States.

Nice To Haves

• Utilization review or discharge planning experience.
• Recent experience or working knowledge of medical necessity review criteria.
• Current working knowledge of quality improvement processes.
• Experience with EMR systems in addition to Epic.
• RN compact license preferred.

Responsibilities

• Use proactive triggers, diagnoses, cost criteria, and complications to identify potential over- or under-utilization of services.
• Refer cases to a physician advisor in a timely manner and help identify barriers to patient progress with the interdisciplinary team.
• Coordinate with financial clearance, patient access, financial counselors, and business offices on third-party payer billing issues.
• Conduct medical necessity reviews of admissions using approved clinical review criteria, including patient status and continued-stay reviews.
• Provide inpatient and 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 relevant parties.
• Collaborate with in-house staff and physicians to clarify information, obtain documentation, identify opportunities, and educate on appropriate level of care.
• Coordinate the peer-to-peer process with physicians or physician advisors, the Financial Clearance Center, and Revenue Cycle teams when assigned; maintain appeal documentation.
• Maintain information to minimize denials; record denial updates and overturned days; monitor and report denial trends; and monitor readmissions.
• Collaborate with the healthcare team to achieve outcome-management goals, including CMS indicators.
• Accurately record and submit statistical data within required time frames; document work and communications with the Financial Clearance Center, payers, physicians, physician advisors, and in-house care management.
• Complete assigned ConnectCare and ADT work queues and send second-level physician reviews as required, documenting responses and actions.
• Prioritize patient reviews based on situational analysis, functional assessment, medical record review, and clinical review criteria.
• Maintain communication and rapport with in-house care managers and provide age-appropriate care-related review based on patient status, needs, and developmental considerations.
• Direct physician and patient communication regarding non-coverage of benefits; educate hospital and medical staff about the utilization review program.
• Maintain professional communication with physicians, nurses, multidisciplinary team members, and administration; respond to voicemail, Skype, email, and Financial Clearance Center communications in a timely manner.
• Be available for designated meetings and training, onsite or online, and use hospital-provided communication devices during work hours.
• Work collaboratively with peers, share workload, provide backup support, and participate in departmental process improvement activities.
• Comply with department and Financial Clearance Center policies, confidentiality requirements, 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 assigned community committees.
• Perform other job-related duties as required, subject to reasonable accommodation.

Benefits

• Bonus incentives, including quarterly and annual incentive programs.
• 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