Remote Utilization Review RN: Denials & Medical Necessity

Ensemble Health Partners; United States; Remote; USD 63,000 - 95,000; Full time

Benefits offered by this job

Bonus Incentives

Shift Differentials

Paid Certifications

Tuition Reimbursement

Comprehensive Benefits

Career Advancement

Job summary

Ensemble Health Partners is seeking a Virtual Utilization Review Specialist to join our remote team. You will perform medical necessity reviews, manage denials, and coordinate with FCC and care management to optimize patient care while controlling costs.

Qualified candidates hold a current RN license, have at least 1 year in denials management and utilization review, and are proficient with Epic EMR. This remote role requires strong communication, collaboration, and adherence to CMS guidelines.

Qualifications

• Bachelor's degree in Nursing or related field
• Current RN license required
• Experience in utilization review and denial management preferred
• Proficiency with Epic EMR and CMS guidelines

Responsibilities

• Coordinate denial management with the Financial Clearance Center and care management
• Conduct medical necessity reviews using approved criteria
• Identify barriers to patient progress and collaborate with interdisciplinary team
• Document and communicate outcomes to relevant stakeholders
• Support revenue integrity and avoid unnecessary utilization

Skills

Utilization review

Denial management

CMS guidelines

Communication

Team collaboration

Education

Bachelor's degree in Nursing or related field

Tools

Epic EMR

InterQual

MCG criteria

Job description

Ensemble Health Partners is seeking a Virtual Utilization Review Specialist to join our remote team. You will perform medical necessity reviews, manage denials, and coordinate with FCC and care management to optimize patient care while controlling costs.

Qualified candidates hold a current RN license, have at least 1 year in denials management and utilization review, and are proficient with Epic EMR. This remote role requires strong communication, collaboration, and adherence to CMS guidelines.