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Ensemble Health Partners

End-to-end revenue cycle management for hospitals

Lead Utilization Review - RN

Medical, Clinical & VeterinaryConfirmed live in the last 24 hours
Full-timeRemote in USA

About the Job

Requirements

  • A current unrestricted registered nurse license is required.
  • At least five years of nursing experience in an acute care environment is required.
  • Experience in utilization review or discharge planning is required.
  • A bachelor's degree in Nursing is preferred; an associate degree in Nursing is required.
  • Recent working knowledge of medical necessity review criteria is preferred.
  • Ability to communicate ideas effectively verbally and in writing.
  • Ability to collaborate with all members of the care team.
  • Strong clinical assessment, organization, and problem-solving skills.
  • Ability to assess and identify appropriate internal and community resources for an assigned caseload and collaborate with the health care team, providers, and payors to achieve patient, quality, and financial outcomes.
  • Ability to organize information quickly and effectively, prioritize, and complete multiple tasks effectively.
  • Strong technical skills, including database and spreadsheet analysis.
  • Must be willing and able to work within the department's scheduled hours of 8:00 a.m. to 10:00 p.m., including weekends as needed.
  • Must reside and be authorized to work within the United States.

Responsibilities

  • Use proactive triggers, including diagnoses, cost criteria, and complications, to identify potential over- or under-utilization of services and refer matters to the physician advisor in a timely manner.
  • Understand appropriate health care resource utilization, identify barriers to patient progress, and collaborate with the hospital liaison.
  • Collaborate with the financial clearance center, patient access, financial counselors, and/or business office regarding third-party-payer billing issues.
  • Conduct daily medical necessity reviews of admissions using approved clinical review criteria, including appropriate patient status and continued-stay reviews, potentially from an offsite location.
  • Provide inpatient and observation clinical reviews for commercial carriers within one business day of admission when indicated.
  • Communicate medical necessity review outcomes to the hospital liaison; clarify information, obtain documentation, present opportunities, and educate on appropriate level of care in collaboration with the liaison.
  • Coordinate the appeal process with the liaison, Financial Clearance Center, and Revenue Cycle team when necessary and assigned, and maintain relevant appeal documentation.
  • Maintain information to minimize denial rates; record denial updates and overturned days, monitor and report denial trends, and monitor and report potential and current readmissions to the liaison.
  • Evaluate medical records for discharge-planning needs and make timely referrals to the care team and/or liaison to support timely discharge and connection with post-discharge care providers.
  • Collaborate with the health care team to achieve outcomes-management goals, including CMS indicators, and accurately record and submit statistical data within required time frames.
  • Complete assigned ConnectCare and ADT work queues for case-management revenue-cycle workflow and document work and communications with the Financial Clearance Center and hospital-based liaison.
  • Send second-level physician reviews as required and document responses and actions.
  • Prioritize patient-care needs using situational analysis, functional assessment, medical-record review, and clinical review criteria.
  • Collaborate with the liaison to develop and expand the plan of care to address multidisciplinary patient-care needs, monitor and evaluate the plan, identify variances, make adjustments to ensure continuity, and direct care toward predictable outcomes.
  • Provide care appropriate to the age and needs of assigned patients, applying knowledge of lifespan growth and development and interpreting status data to identify patient requirements.
  • Direct physician and patient communications regarding non-coverage of benefits to the liaison.
  • Maintain open communication with physicians, nurses, multidisciplinary team members, the liaison, and administration; educate hospital and medical staff about the case-management program.
  • Maintain a professional demeanor during conflict or crisis, answer voicemail in a timely manner, use hospital-provided communication devices during work hours, and be available for designated meetings or training unless prior arrangements are made.
  • Collaborate respectfully with peers, communicate clearly and timely, share workload, provide backup support, and participate in departmental process-improvement activities, including planning, implementation, and evaluation.
  • Comply with hospital 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, MS-DRGs, and POA.
  • Participate in departmental meetings and activities, hospital and community committees as assigned, conferences, committees, and task forces; perform other duties as assigned.

Desired Qualifications

  • Recent working knowledge and experience with medical necessity review criteria.
  • A bachelor's degree in Nursing.

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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