Remote RN Utilization & Denials Specialist

Santa Barbara Cottage Hospital; United States; Remote; USD 68,000 - 91,000; Full time

Benefits offered by this job

Bonus incentives

Paid certifications

Tuition reimbursement

Comprehensive benefits

Career advancement

Job summary

Ensemble is seeking a Virtual Utilization Review Specialist to join our remotely-based team. The role requires at least 1 year in denials management and 5+ years of acute care clinical experience, with RN licensure and Epic EMR familiarity.

Expect a Monday–Friday schedule with some weekend coverage and opportunities for certifications and tuition reimbursement. We value patient-centered care, collaboration, and innovation, offering comprehensive benefits and career advancement.

Qualifications

• Bachelor's degree or equivalent experience; Specialty/Major: Nursing or related field.
• Current unrestricted RN license required; RN compact license preferred
• Utilization review/discharge planning experience preferred
• Recent experience or working knowledge of medical necessity review criteria preferred
• Current working knowledge of quality improvement processes

Responsibilities

• Resource Utilization: Identify potential over/under utilization using triggers and advise physician when needed.
• Medical Necessity Determination: Review admissions for medical necessity and provide timely consultations.
• Denial Management: Coordinate denial processes and monitor trends.
• Quality/Revenue Integrity: Record data for CMS indicators and ensure accuracy of documentation.
• Facilitation of Patient Care: Prioritize reviews and collaborate with care managers to meet patient needs.
• Communication: Maintain open communication with physicians, nurses, and staff; educate on utilization reviews.
• Team Affimation: Work with peers to achieve departmental goals and participate in process improvements.

Skills

Acute care

Utilization review

Denial management

Medical necessity criteria

Communication skills

Epic EMR

Education

Bachelor's Degree or equivalent experience; Nursing or related field

Tools

Epic EMR

Job description

Ensemble is seeking a Virtual Utilization Review Specialist to join our remotely-based team. The role requires at least 1 year in denials management and 5+ years of acute care clinical experience, with RN licensure and Epic EMR familiarity.

Expect a Monday–Friday schedule with some weekend coverage and opportunities for certifications and tuition reimbursement. We value patient-centered care, collaboration, and innovation, offering comprehensive benefits and career advancement.