Remote Lead Utilization Review RN

Ensemble Health Partners; Columbus (OH); 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 Health Partners is seeking a Lead Utilization Review RN to drive medical necessity reviews, discharge planning, and appeals coordination while collaborating with physicians, nurses, and payors. The role supports revenue cycle integrity and patient care quality in a remote US-based environment.

You will evaluate admissions, coordinate with hospital staff and financial services, and ensure documentation reflects services provided.

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.
• Strong communication and problem solving skills.

Responsibilities

• RESOURCE UTILIZATION: Identify potential over/under utilization, refer to physician advisor, collaborate with hospital liaison and billing teams.
• MEDICAL NECESSITY DETERMINATION: Review admissions for medical necessity, apply criteria, perform ongoing reviews for inpatient/observation status.
• DENIAL MANAGEMENT: Coordinate appeals, maintain documentation, monitor denial trends and readmissions.
• DISCHARGE PLANNING: Assess discharge needs, refer to care team, ensure timely linkage with post-discharge care providers.
• FACILITATION OF PATIENT CARE: Plan care with the liaison, adjust plans for predictable outcomes, ensure age-appropriate care and family communication.
• COMMUNICATION: Manage non-coverage discussions, educate staff, maintain professional demeanor and timely responses.
• TEAM AFFIRMATION: Collaborate with peers, participate in process improvement, provide back-up support and share responsibilities.
• OTHER JOB FUNCTIONS: Maintain policies, keep up-to-date on regulatory requirements, participate in meetings and committees.

Skills

RN License

Nursing Experience

Utilization Review

Discharge Planning

Communication Skills

Clinical Assessment

Education

Bachelor's degree in Nursing

Associates degree in Nursing

Tools

MS Excel

EMR Systems

Job description

Ensemble Health Partners is seeking a Lead Utilization Review RN to drive medical necessity reviews, discharge planning, and appeals coordination while collaborating with physicians, nurses, and payors. The role supports revenue cycle integrity and patient care quality in a remote US-based environment.

You will evaluate admissions, coordinate with hospital staff and financial services, and ensure documentation reflects services provided.