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Ensemble Health Partners

End-to-end revenue cycle management for hospitals

Utilization Review RN - Denials

Medical, Clinical & VeterinaryPosted on Nov 11
Full-timeRemote in USA

About the Job

Requirements

  • A bachelor's degree or equivalent experience in Nursing or a related field.
  • A current unrestricted registered nurse license is required; a compact registered nurse license is preferred, or the candidate must be willing to obtain one.
  • At least five years of acute care clinical experience.
  • At least two years of utilization review experience.
  • At least one year of denial management experience.
  • Demonstrated proficiency with InterQual and MCG criteria.
  • Required experience with Epic electronic medical record; experience with additional electronic medical record systems is preferred.
  • Current working knowledge of quality improvement processes.
  • A strong understanding of Centers for Medicare & Medicaid Services guidelines and their application in clinical review processes.
  • Access to high-speed internet is required for this remote role.
  • Candidates must reside and be authorized to work within the United States.
  • Candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require.
  • Ability to work independently, exercise critical thinking and clinical judgment, manage multiple priorities and deadlines, organize work, and prioritize workload.
  • Ability to collaborate effectively within a multidisciplinary team while remaining accountable for individual responsibilities.
  • Strong technical aptitude and ability to learn, adapt to, and use healthcare technologies and software applications.
  • Ability to demonstrate openness to innovation, including artificial intelligence, to explore better processes and improve patient and client experiences.

Responsibilities

  • Use proactive triggers, including diagnoses, cost criteria, and complications, to identify potential over- or under-utilization of services.
  • Initiate appropriate referrals to a physician advisor in a timely manner.
  • Apply knowledge of appropriate healthcare resource utilization, identify barriers to patient progress, and collaborate with the interdisciplinary team.
  • Collaborate with the financial clearance center, patient access, financial counselors, and business office regarding third-party payer billing issues.
  • Conduct medical necessity reviews for admissions using approved clinical review criteria, including patient status and continued-stay reviews, potentially from an offsite location.
  • Provide inpatient and observation clinical reviews, when indicated, for commercial carriers to the Financial Clearance Center within one business day of admission.
  • Communicate medical necessity review outcomes to in-house care management staff and relevant parties as needed.
  • Work with in-house staff and physicians to clarify information, obtain documentation, present opportunities, and educate regarding appropriate level of care.
  • Coordinate the peer-to-peer process with physicians or physician advisors, the Financial Clearance Center, and the Revenue Cycle team when assigned, and maintain appeal-related documentation.
  • Maintain information on file to minimize denial rates; record denial updates and overturned days; monitor and report denial trends; and monitor readmissions.
  • Collaborate with healthcare team members to achieve outcomes management goals, including Centers for Medicare & Medicaid Services indicators.
  • Record data accurately for statistical entry and submit it within required time frames.
  • Handle ConnectCare and admission-discharge-transfer work queues assigned to virtual utilization review for revenue cycle workflow.
  • Document work and communications related to the Financial Clearance Center, payers, physicians, physician advisors, and in-house care management.
  • Send second-level physician reviews as required and document responses and actions.
  • Prioritize patient reviews using situational analysis, functional assessment, medical record review, and clinical review criteria.
  • Maintain rapport and communication with the in-house care manager and provide care appropriate to assigned patients' ages and needs, consistent with departmental policies and procedures.
  • Direct physician and patient communication regarding non-coverage of benefits.
  • Maintain communication with physicians, nurses, multidisciplinary team members, and administration; answer voicemail, Skype, and email in a timely manner; and acknowledge Financial Clearance Center communications under approved guidelines and service-line agreements.
  • Educate hospital and medical staff regarding the utilization review program.
  • Be available for designated meetings or training, onsite or online, unless prior arrangements are made; use hospital-provided communication devices during work hours.
  • Work collaboratively with peers, communicate respectfully and clearly, share responsibilities, provide backup support, and assist colleagues as needed.
  • Participate in departmental process-improvement activities, meetings, and activities; participate in Financial Clearance Center and community committees, conferences, and task forces as assigned.
  • Comply with Financial Clearance Center and department policies and procedures, including confidentiality and patient rights.
  • Maintain clinical competency and current knowledge of regulatory and payer requirements, including medical necessity criteria, Medicare Severity Diagnosis-Related Groups, and present-on-admission indicators.
  • Perform other job-related duties as required by the supervisor, subject to reasonable accommodation.

Desired Qualifications

  • Utilization review or discharge planning experience is preferred.
  • Recent experience or working knowledge of medical necessity review criteria is preferred.
  • Experience with additional electronic medical record systems is preferred.
  • A current compact registered nurse license is preferred.

About the Company

Ensemble Health Partners

End-to-end revenue cycle management for hospitals

Ensemble Health Partners provides end-to-end revenue cycle management for hospitals and health systems. It handles the entire process from patient intake to final payment, with teams and technology embedded into the provider's operations and a revenue model tied to performance improvements. The company uses its proprietary EIQ platform (analytics, AI, and workflow automation) to optimize revenue cycle processes, reduce insurance denials, and speed cash collection, managing more than $39 billion in net patient revenue. Its approach differentiates it by being a true managed-services partner with full accountability for financial outcomes and a track record of meeting initial client goals. The overarching goal is to improve healthcare providers’ financial performance so they can focus on patient care.

Company size
5,001-10,000
Company stage
Not listed
Total funding
Not listed
Headquarters
Cincinnati, OH
Founded
2014

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