Remote Utilization Review RN – Pediatric/NICU Focus

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

Job summary

Ensemble Health Partners is seeking an experienced RN for utilization review and medical necessity determinations in a remote capacity across the United States. The role emphasizes coordination with care management, FCC, and payers to optimize patient outcomes and revenue cycle efficiency.

Qualified candidates hold a Bachelor’s in Nursing with an unrestricted RN license (compact license preferred) and 3+ years in acute care.

Qualifications

• Bachelor’s Degree or equivalent experience; Specialty/Major: Nursing or related field.
• Current unrestricted RN license required; RN compact license preferred.
• Three years nursing experience in an acute care environment 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

• Utilizes proactive triggers (diagnoses, cost criteria, and complications) to identify potential over/under utilization of services
• Initiates appropriate referral to physician advisor in a timely manner
• Understands proper utilization of health care resources and assists with identifying barriers to patient progress and collaborates with the interdisciplinary team
• Collaborates with financial clearance center, patient access, financial counselors and/or business office regarding billing issues related to third party payers
• Demonstrates active collaboration with other members of the health care team to achieve outcomes management goals including CMS indicators
• Documentation will reflect all work and communication related to the FCC, payor, physician, physician advisor and in-house care management
• Actively participates in departmental meetings and activities
• Participates in FCC and community committees as assigned
• Assists in denial management and readmissions monitoring

Skills

RN nursing

Neonatal care

Pediatric care

Utilization review

Education

Bachelor’s Degree in Nursing

RN license (compact preferred)

Job description

Ensemble Health Partners is seeking an experienced RN for utilization review and medical necessity determinations in a remote capacity across the United States. The role emphasizes coordination with care management, FCC, and payers to optimize patient outcomes and revenue cycle efficiency.

Qualified candidates hold a Bachelor’s in Nursing with an unrestricted RN license (compact license preferred) and 3+ years in acute care.