Virtual Utilization Review Lead

Ensemble Health Partners; United States; On-site; USD 84,000 - 126,000; Full time

Benefits offered by this job

Bonus incentives

Paid certifications

Tuition reimbursement

Comprehensive benefits

Career advancement

Job summary

Ensemble Health Partners is seeking a Virtual Utilization Review Supervisor within the United States. The role focuses on clinical and financial performance, driving medical necessity reviews, and coordinating denials management in a patient-centered care model.

You will supervise utilization review activities, mentor staff, and collaborate with hospital teams to optimize care and cost efficiency while ensuring compliant documentation and CMS reporting.

Qualifications

• Current unrestricted RN license is required.
• 1+ year of leadership and/or coaching experience.
• 2+ years UR experience.
• 5+ years of nursing experience in an acute care environment required.
• Experience in utilization review/discharge planning.
• Strong communication and collaboration with the care team.

Responsibilities

• Utilizes proactive triggers to identify potential over/under utilization and refers to physician advisor.
• Conducts medical necessity reviews for admissions and appropriate level of care.
• Coordinates the appeal process and tracks denial trends.
• Documents data for CMS indicators and supports revenue cycle workflows.
• Prioritizes patient care and expands the plan of care with the care team.
• Directs physician and patient communication regarding non-coverage of benefits.

Skills

Utilization review

Discharge planning

Leadership experience

Nursing experience

Clinical collaboration

Education

Bachelor's degree nursing preferred; Associates degree nursing required

MCG certification

Job description

Ensemble Health Partners is seeking a Virtual Utilization Review Supervisor within the United States. The role focuses on clinical and financial performance, driving medical necessity reviews, and coordinating denials management in a patient-centered care model.

You will supervise utilization review activities, mentor staff, and collaborate with hospital teams to optimize care and cost efficiency while ensuring compliant documentation and CMS reporting.