Senior Utilization Review RN - Quality & Efficiency Leader

Ensemble Health Partners; Oregon; Hybride; USD 54 000 - 73 000; Plein temps

Résumé du poste

Ensemble seeks a Lead Utilization Review RN to support financial, quality, and clinical performance. The role emphasizes patient-centered care and collaboration with physicians, nurses, and coding professionals to ensure accurate documentation and appropriate care levels.

Responsibilities include medical necessity reviews, discharge planning, and denial management, with a focus on minimizing unnecessary utilization and improving outcomes. Weekend coverage may be required.

Qualifications

• Current RN license with active practice in nursing.
• 5+ years nursing experience in acute care or hospital settings.
• Experience in utilization review, discharge planning, and medical necessity review.
• Communicates effectively with physicians, care teams, and payors.

Responsabilités

• RESOURCE UTILIZATION: Identify over/under utilization; refer to physician advisor; collaborate with hospital liaison and billing.
• MEDICAL NECESSITY DETERMINATION: Review admissions daily using criteria; provide inpatient/observation reviews; communicate outcomes.
• DENIAL MANAGEMENT: Coordinate appeals; monitor denial trends; document updates and readmissions.
• DISCHARGE PLANNING: Assess discharge needs and refer to care teams for timely linkage to post-discharge care.
• QUALITY/REVENUE INTEGRITY: Collaborate with care teams; report CMS indicators; ensure data accuracy.

Connaissances

RN license

Nursing experience

Utilization review

Discharge planning

Medical necessity review

Communication

Team collaboration

Formation

Bachelor's degree in Nursing

Associate degree in Nursing

Description du poste

Ensemble seeks a Lead Utilization Review RN to support financial, quality, and clinical performance. The role emphasizes patient-centered care and collaboration with physicians, nurses, and coding professionals to ensure accurate documentation and appropriate care levels.

Responsibilities include medical necessity reviews, discharge planning, and denial management, with a focus on minimizing unnecessary utilization and improving outcomes. Weekend coverage may be required.