Lead Utilization Review RN - Discharge & Denial Leader

Ensemble Health Partners; Ohio; Hybrid; USD 54,000 - 73,000; Full time

Benefits offered by this job

Bonus incentives

Paid certifications

Tuition reimbursement

Comprehensive benefits

Career advancement

Job summary

Ensemble Health Partners is seeking a Lead Utilization Review RN to drive financial and clinical performance across the organization. You will oversee medical record reviews, determine appropriate levels of care, and coordinate with physicians, nurses, and coding professionals to ensure accurate documentation reflecting services rendered.

You will analyze utilization, manage denials, and collaborate with financial clearance, patient access, and care teams to support compliant, cost-effective

Qualifications

• Current unrestricted RN license is required.
• 5+ years of nursing experience in an acute care environment.
• Experience in utilization review / discharge planning.
• Recent and working knowledge of medical necessity review criteria experience preferred.

Responsibilities

• Utilizes proactive triggers to identify potential over/under utilization of services and collaborates with hospital liaison.
• Conducts medical necessity review of admissions and provides inpatient/observation reviews.
• Coordinates the appeal process for denials and monitors denial trends.
• Evaluates discharge planning needs and makes referrals to care team and liaison.
• Documents data for statistical entry and CMS indicators and supports revenue cycle workflow.

Skills

Verbal & written communication

Team collaboration

Clinical assessment

Problem solving

Organization

Database & spreadsheet analysis

Education

Associates degree Nursing

Bachelors degree Nursing preferred

Tools

Database analysis

Spreadsheet analysis

Job description

Ensemble Health Partners is seeking a Lead Utilization Review RN to drive financial and clinical performance across the organization. You will oversee medical record reviews, determine appropriate levels of care, and coordinate with physicians, nurses, and coding professionals to ensure accurate documentation reflecting services rendered.

You will analyze utilization, manage denials, and collaborate with financial clearance, patient access, and care teams to support compliant, cost-effective