Virtual Utilization Review Supervisor

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

21h • $84,000 - $126,000 • Remote

About The Position

The Virtual Utilization Review Supervisor contributes to the organization’s financial, quality, and clinical performance by supporting an outcomes-oriented patient care system. The role facilitates improvements in the quality and completeness of medical record documentation and supports accurate reflection of services rendered and clinical information used in profiling and reporting outcomes. Through collaboration with physicians, nurses, other caregivers, coding professionals, hospital liaisons, and revenue cycle teams, the Supervisor helps ensure care is medically necessary, delivered in the appropriate setting, and consistent with governmental and regulatory standards.

The position oversees utilization review activities, including medical necessity reviews, resource utilization, denial management, quality and revenue integrity workflows, and coordination of patient care. It also supports communication and education among hospital and medical staff, maintains current knowledge of clinical and regulatory requirements, and contributes to departmental improvement and team support. The position is virtual/remote and is limited to individuals residing and authorized to work in the United States.

Requirements

• Current unrestricted RN license.
• At least 1 year of leadership and/or coaching experience.
• At least 2 years of utilization review experience.
• At least 5 years of nursing experience in an acute care environment.
• Associate degree in Nursing required.
• Current MCG certification or willingness to obtain it within 6 months of hire.
• 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 collaborate with healthcare teams, providers, and payors to achieve patient, quality, and financial outcomes.
• Ability to organize information quickly and effectively, prioritize, and complete multiple tasks.
• Strong technical skills, including database and spreadsheet analysis.

Nice To Haves

• Bachelor’s degree in Nursing preferred.
• Experience in utilization review and discharge planning.
• Recent, working knowledge of medical necessity review criteria.

Responsibilities

• Use proactive triggers, including diagnoses, cost criteria, and complications, to identify potential over- or under-utilization of services; refer cases to a physician advisor when appropriate and 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 offices on third-party payer billing issues.
• Conduct daily medical necessity reviews of admissions using approved clinical review criteria, including appropriate patient status and continued-stay reviews.
• Provide inpatient and, when indicated, observation clinical reviews for commercial carriers within one business day of admission.
• Communicate medical necessity review outcomes to the hospital liaison; collaborate to clarify information, obtain documentation, present opportunities, and educate on appropriate levels of care.
• Coordinate the appeal process with the liaison and Revenue Cycle team when necessary and assigned; maintain appeal documentation and information to help minimize denials.
• Record denial updates and overturned days, monitor and report denial trends, and monitor and report potential and current readmissions to the liaison.
• 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 case-management work queues for revenue cycle workflow and document work and communications related to the Financial Clearance Center and hospital-based liaison.
• Send second-level physician reviews as required and document responses and actions.
• Prioritize patient care needs using situational analysis, functional assessment, medical record review, and clinical review criteria.
• Collaborate with the liaison to develop and expand multidisciplinary plans of care, monitor and evaluate those plans, address variances, and direct care toward predictable outcomes and continuity.
• Apply knowledge of age-appropriate care and lifespan growth and development to assess patient status and identify care requirements.
• Direct physician and patient communications regarding non-coverage of benefits to the liaison and maintain professional communication with physicians, nurses, multidisciplinary team members, liaisons, and administration.
• Educate hospital and medical staff about the case management program and respond to voicemail and approved communications in a timely manner.
• Use hospital-provided communication devices during work hours and be available for designated meetings and training unless prior arrangements are made.
• Work collaboratively with peers, communicate respectfully and clearly, 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.
• Participate in departmental meetings, activities, hospital and community committees as assigned, and conferences, committees, and task forces as directed by the case management division.

Benefits

• Bonus incentives and quarterly and annual incentive programs.
• Paid certifications and professional certification relevant to the associate’s field.
• Tuition reimbursement.
• Comprehensive benefits supporting physical, emotional, and financial health, 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: Manager
• Education Level: Associate degree