Remote Utilization Review RN – Denials & Care Management

Ensemble Health Partners; Kentucky; Hybrid; USD 63,000 - 95,000; Full time

Job summary

Ensemble Health Partners is seeking a Virtual Utilization Review Specialist to join our remote team. You will review medical necessity, coordinate denial management, and support CMS-compliant care across the patient care continuum.

Required are 5+ years in acute care, 2+ years utilization review, 1+ year denial management, and proficiency with Epic EMR. You will work with a multidisciplinary team to optimize patient outcomes while maintaining regulatory standards.

Qualifications

• 5+ years of acute care clinical experience.
• Minimum of 2 years of utilization review experience.
• At least 1 year of denial management experience.
• Familiar with CMS guidelines and clinical review processes.
• Willing to travel to client sites as needed.

Responsibilities

• Resource Utilization – identify over/under utilization and refer to physician advisor.
• Medical Necessity Determination – conduct reviews for admissions and communicate outcomes.
• Denial Management – coordinate appeals and monitor trends.
• Quality/Revenue Integrity – record data and CMS indicators.
• Documentation – record all work and communications.
• Facilitation of Patient Care – prioritize reviews and collaborate with care management.
• Communication – liaise with physicians and hospital staff and keep stakeholders informed.

Skills

Acute care clinical experience

Utilization review experience

Denial management experience

Multidisciplinary teamwork

Epic EMR proficiency

Education

Bachelor's Degree or equivalent experience; Specialty/Major: Nursing or related field

Tools

Epic EMR

Job description

Ensemble Health Partners is seeking a Virtual Utilization Review Specialist to join our remote team. You will review medical necessity, coordinate denial management, and support CMS-compliant care across the patient care continuum.

Required are 5+ years in acute care, 2+ years utilization review, 1+ year denial management, and proficiency with Epic EMR. You will work with a multidisciplinary team to optimize patient outcomes while maintaining regulatory standards.