Senior Quality RN

Ensemble Health Partners; Ohio; Remote; USD 90,000 - 120,000; Full time

Job summary

Ensemble Health Partners is seeking a Senior Utilization Review Quality RN to review the quality of VUR work across cases, partner with leadership, and identify opportunities for process improvements. The role includes onboarding support and mentoring UR staff to enhance the quality review process.

Travel to client sites or corporate offices as needed is required. Candidates should bring strong nursing experience, UR knowledge, and a commitment to compliance and customer service.

Qualifications

• Bachelor's Degree in Nursing or equivalent.
• Current unrestricted RN license.
• 3 years nursing in an acute care environment.
• Utilization review experience preferred.
• Recent experience with medical necessity review criteria preferred.
• Knowledge of quality improvement processes.
• Excellent interpersonal, communication and negotiation skills.
• Commitment to exceptional customer service.

Responsibilities

• Perform independent account reviews on cases handled by UR team with recommendations for improvement.
• Mentor UR Quality staff to develop review skills.
• Coordinate with leaders to identify risks and develop annual review plans.
• Prepare and present quality reports to leadership for review and approval.
• Assist with onboarding support including user provisioning.
• Maintain knowledge of laws/regulations regarding medical necessity and compliance.
• Identify and mitigate operational and quality risks and document findings.
• Perform root cause analysis on audit findings and denials.

Skills

Interpersonal skills

Communication

Quality improvement

Team collaboration

Education

Bachelor's Degree in Nursing

RN license

Job description

About Ensemble

Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. 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.

Customer Obsession:

Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.

Bonus Incentives

• Bonus Incentives
• Tuition Reimbursement

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.

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.
• 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. 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.
• 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.

This is a 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.

#LI-Remote

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 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
• 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
• 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

Eligibility/Compliance

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.

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 equity;

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.

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.
• Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.

Awards

• 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
• Fortune Media Best Workplaces in Healthcare 2024
• Monster Top Workplace for Remote Work 2024