RN, Senior Utilization Review Quality

Ensemble Health Partners; Ohio; Hybrid; USD 65,000 - 87,000; Full time

Benefits offered by this job

Tuition reimbursement

Certification programs

Career growth

Job summary

Ensemble Health Partners is seeking an RN Utilization Review quality professional to lead QA efforts within the VUR team. You will mentor staff, evaluate QA processes, and drive improvements across multiple clients and systems.

The role requires an unrestricted RN license, at least three years of acute care nursing experience, and knowledge of medical necessity review criteria. Remote work with travel to client sites is expected, and opportunities for professional development are provided.

Qualifications

• Bachelor's Degree or equivalent; Nursing or related field
• Current unrestricted RN license required; RN compact license preferred
• Three years nursing experience in an acute care environment required
• Utilization review/discharge planning experience preferred
• Current knowledge of quality improvement processes

Responsibilities

• Mentor UR Quality Specialists and UR team members to develop skills in the quality review process
• Assess QA processes and identify opportunities to increase efficiency and inform Leadership
• Evaluate VUR policies/procedures for entry level and senior teams and contribute to annual review workplan
• Perform quality reviews across multiple clients and host systems
• Document operational, compliance, and quality risks and propose mitigations
• Prepare and present quality reports to leadership for review and approval
• Support onboarding including user provisioning with Leadership Team
• Maintain knowledge of medical necessity and regulatory requirements related to service line

Skills

Communication

Interpersonal skills

Negotiation

Clinical assessment

Organization

Problem solving

Education

Bachelor's Degree in Nursing

RN License

Job description

Company Overview

Thank you for considering a career at Ensemble! Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country. Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference!

Core Purpose

O.N.E Purpose: Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations. Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation. Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results.

The Opportunity

CAREER OPPORTUNITY OFFERING: Bonus Incentives Paid Certifications Tuition Reimbursement Comprehensive Benefits Career Advancement

This position pays between $47.03 - $63.48/hr based on experience Please note that the VUR department operates 7 days per week from 8:00 a.m. to 10:00 p.m., and candidates must be willing and able to work within these scheduled hours, including weekends as needed. By embodying our core purpose of customer obsession, new ideas, and driving innovation, and delivering excellence, you will help ensure that every touchpoint is meaningful and contributes to our mission of redefining the possible in healthcare.

The RN, Senior Utilization Review Quality will play an essential role in reviewing and ensuring the quality of the VUR teams’ work efforts in partnership with the Leadership Team. The primary responsibility of this role is to perform independent account reviews on cases that have been worked by our entry level and senior level Revenue Cycle team members with the purpose of identifying opportunity and making recommendations for improvement to the operational and executive leaders. This role will assist with continued training, education and ongoing action plans to ensure quality is consistently met for existing teams in partnership with the Leadership Team. In addition, this role will be responsible for onboarding support including user provisioning as required in partnership with Leadership Team.

Essential Job Functions

• Mentors other UR Quality Specialist and UR team members to help develop and improve their skills in the quality review process.
• Assesses the Quality Assurance process and actively looks for opportunities to increase efficiency and proactively brings to Leadership attention.
• Evaluate operational and management VUR policies/procedures for entry level and senior level Team to provide input into the annual review workplan.
• Performs Quality reviews across multiple clients, working in a variety of host systems.
• Conduct root cause analysis on audit findings, quality assurance audits and utilization management denials.
• Coordinate with service line leaders and partner with upper level Leadership, to identify areas of risk and assist leadership in developing a quarterly/ annual review plan.
• Develop a thorough understanding of business processes in scope for assigned reviews and document the processes.
• Well versed in VUR processes, protocols, and best practices.
• Perform account level review for entry and senior level individuals to ensure consistency with best practices including but not limited to Quality Audit to confirm implementation and effectiveness of policies/procedures.
• Performs reviews to measure compliance with policies, procedures, workflow, and other applicable requirements.
• Identify and document operational, compliance, and quality risks and make recommendations to mitigate risks.
• Prepare and present quality reports of review findings and recommendations to direct leadership for review and approval.
• Participate in pre- & post-review meetings, providing support and recommendations for issues presented.
• Ensure past review recommendations are implemented in current review process.
• Maintain current knowledge of laws/regulations regarding medical necessity, clinical documentation, compliance standards, reviewing, other general clinical and/or business matters related to the service line they are working.

Experience

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 required Utilization review/discharge planning experience preferred Recent experience or working knowledge of medical necessity review criteria preferred Current working knowledge of quality improvement processes

Other Knowledge, Skills, and Abilities Required

• Excellent interpersonal, communication and negotiatioies Required:n skills in interactions with physicians, payors, and health care team colleagues Commitment to exceptional customer service at all times Communicate ideas and thoughts effectively verbally and in writing Strong clinical assessment, organization and problem-solving skills Ability to assess and identify appropriate resources, internal and community, on assigned caseload, and to work collaboratively with health care team, providers, and payors to achieve the desired patient, quality, and financial outcomes Ability to prioritize, organize information, and complete multiple tasks effectively in a fast-paced environment Resourceful and able to work independently Must be inquisitive and demonstrate openness to innovation including AI to explore better processes and ways to alleviate friction and improve patient and client experiences

Work Arrangement

Remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require

Awards & Recognition

• Five-time winner of “Best in KLAS” 2020-2022, 2024-2025
• Black Book Research's Top Revenue Cycle Management Outsourcing Solution 2021-2024
• 22 Healthcare Financial Management Association (HFMA) MAP Awards for High Performance in Revenue Cycle 2019-2024
• Leader in Everest Group's RCM Operations PEAK Matrix Assessment 2024
• Clarivate Healthcare Business Insights (HBI) Revenue Cycle Awards for strong performance 2020, 2022-2023
• Energage Top Workplaces USA 2022-2024
• Fortune Media Best Workplaces in Healthcare 2024
• Monster Top Workplace for Remote Work 2024
• Great Place to Work certified 2023-2024

Culture & Benefits

Our Culture – Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.

• Associate Benefits – We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.
• Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.
• Recognition – We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company.

Equal Employment Opportunity

Ensemble is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national origin, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws. Ensemble also prohibits harassment of applicants or employees based on any of these protected categories.

Location & Eligibility

Due to business, operational, payroll, and regulatory requirements, this position is limited to individuals who reside and are authorized to work within the United States. Applications generated from outside the United States will not be considered. Individuals may reapply when located within the United States.

Accommodation

Ensemble provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require accommodation in the application process, please contact [e-mail].

Pay Transparency

This posting addresses state specific requirements to provide pay transparency.

Compensation decisions consider many job-related factors, including but not limited to geographic location; knowledge; skills; relevant experience; education; licensure; internal equity; time in position. A candidate entry rate of pay does not typically fall at the minimum or maximum of the role’s range.

About Ensemble

Ensemble is dedicated to providing our clients with experienced healthcare finance and revenue cycle professionals. We believe that our core values of trust, integrity, loyalty and service married with the belief that our work is worthwhile helps us build and sustain sincere relationships with our associates and clients.

Contact and Application

We believe that we foster an environment where talented individuals can excel and shine. Our team believes that people are the most important part of our success and that when we take care of our people, they pay it forward by providing our clients with excellent results and world-class service.