Lead Utilization Review RN: Medical Necessity Expert

Ensemble RCM; United States; Remote; 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 is seeking a Lead Utilization Review Registered Nurse to support outcomes-oriented patient care delivery and drive documentation quality. This role interfaces with physicians, nurses, coding professionals, and hospital staff to verify that care meets medically necessary criteria and reflects services rendered.

The Lead UR collaborates with financial clearance centers and clinical teams to optimize reimbursement, patient flow, and resource use while maintaining regulatory compliance and

Responsibilities

• RESOURCE UTILIZATION: Utilizes proactive triggers (diagnoses, cost criteria, and complications) to identify potential over/under utilization of services. Initiates appropriate referral to physician advisor in a timely manner.
• MEDICAL NECESSITY DETERMINATION: Conducts medical necessity review of all admissions daily and uses criteria to determine necessity for admissions and continued stay.
• DENIAL MANAGEMENT: Coordinates the appeal process with the liaison and Revenue Cycle team, maintains documentation to minimize denial rate and tracks trends.
• DISCHARGE PLANNING: Evaluates discharge planning needs and refers to care team to ensure timely discharge and appropriate linkage with post-discharge care providers.
• QUALITY/REVENUE INTEGRITY: Collaborates with team to ensure documentation quality and financial integrity across processes.

Job description

Ensemble is seeking a Lead Utilization Review Registered Nurse to support outcomes-oriented patient care delivery and drive documentation quality. This role interfaces with physicians, nurses, coding professionals, and hospital staff to verify that care meets medically necessary criteria and reflects services rendered.

The Lead UR collaborates with financial clearance centers and clinical teams to optimize reimbursement, patient flow, and resource use while maintaining regulatory compliance and