Senior RN, Utilization Review Quality - Remote

Ensemble Health Partners; Columbus (OH); Remote; USD 65,000 - 87,000; Full time

Benefits offered by this job

Bonus incentives

Paid certifications

Tuition reimbursement

Comprehensive benefits

Career advancement

Job summary

Ensemble Health Partners seeks an RN for Senior Utilization Review Quality to oversee quality reviews and mentor UR staff. You will partner with Leadership to improve processes, ensure policy adherence, and support training and onboarding.

Remote role with travel to client sites as needed; requires RN license, acute care experience, and knowledge of medical necessity criteria. Includes certification support and career growth opportunities.

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

Responsibilities

• Mentors UR Quality Specialists and team members to improve skills in the quality review process.
• Assesses the Quality Assurance process and identifies opportunities to increase efficiency.
• Evaluate VUR policies/procedures for entry level and senior teams for annual planning.
• Performs Quality reviews across multiple clients in various host systems.
• Conduct root cause analysis on audit findings and denials.
• Coordinate with service line leaders to identify risk and plan reviews.
• Develop understanding of business processes and document them.
• Ensure compliance with VUR processes, protocols, and best practices.
• Perform account level reviews to ensure policy adherence.
• Prepare and present quality reports to leadership for review.
• Participate in pre- and post-review meetings and implement past recommendations.
• Maintain knowledge of laws/regulations regarding medical necessity and compliance.

Skills

RN license

Communication

Quality review

Problem-solving

Organization

Independent work

Open to AI innovations

Education

Bachelor's degree or higher (Nursing)

Job description

Ensemble Health Partners seeks an RN for Senior Utilization Review Quality to oversee quality reviews and mentor UR staff. You will partner with Leadership to improve processes, ensure policy adherence, and support training and onboarding.

Remote role with travel to client sites as needed; requires RN license, acute care experience, and knowledge of medical necessity criteria. Includes certification support and career growth opportunities.