Remote Utilization Review RN – Denials & Care Optimization

Ensemble Health Partners; Blue Ash (OH); Remote; USD 63,000 - 95,000; Full time

Benefits offered by this job

Bonus Incentives

Shift Differentials

Tuition Reimbursement

Paid Certifications

Comprehensive Benefits

Job summary

Ensemble Health Partners seeks aRemote Utilization Review Specialist with Nursing background to conduct medical necessity reviews and coordinate with care teams. The role emphasizes accurate evaluations, timely communication, and collaboration with the FCC and physicians.

Ideal candidates have acute care experience, strong knowledge of CMS guidelines, and comfort working remotely with flexible scheduling, including occasional weekend coverage.

Qualifications

• BSN required with RN license.
• At least 2 years in utilization review or related field.
• Experience with InterQual and MCG criteria.
• Strong communication and ability to work remotely.

Responsibilities

• Reviews medical necessity for admissions using criteria.
• Conducts inpatient and observation reviews for commercial carriers.
• Collaborates with FCC, patient access, and care management.
• Coordinates P2P process with physician advisor and Revenue Cycle team.
• Tracks denial trends and supports appeals.

Skills

RN license

Utilization review

Denials management

InterQual & MCG criteria

Epic EMR

Communication skills

Independent work

Education

Bachelor's Degree in Nursing

Tools

Epic EMR

Other EMR systems

Job description

Ensemble Health Partners seeks aRemote Utilization Review Specialist with Nursing background to conduct medical necessity reviews and coordinate with care teams. The role emphasizes accurate evaluations, timely communication, and collaboration with the FCC and physicians.

Ideal candidates have acute care experience, strong knowledge of CMS guidelines, and comfort working remotely with flexible scheduling, including occasional weekend coverage.