Utilization Review RN

Thank you for considering a career at Ensemble! Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country. Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference! O.N.E Purpose: Customer Obsession:  Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations. Embracing New Ideas:  Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation. Striving for Excellence:  Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results. The Opportunity: CAREER OPPORTUNITY OFFERING: Bonus Incentives Shift Differentials Paid Certifications Tuition Reimbursement Comprehensive Benefits Career Advancement Salary Range: $63,100 - $94,650 annually , dependent upon experience, education, certifications, and overall qualifications. *Must have current compact RN license, or be willing to obtain* NICU and/or Pediatric nursing experience is strongly preferred. We are specifically seeking nurses with experience caring for neonatal, infant, and pediatric patient populations. Candidates with clinical backgrounds in NICU, PICU, pediatric acute care, pediatric specialty care, or related settings are highly encouraged to apply. Schedule Information: Our Utilization Review team provides coverage seven days a week, operating between 8:00 a.m. and 10:00 p.m. To support our patients and partners, team members are scheduled within these hours, including weekends on a rotating basis. This role follows a 4x10 schedule , meaning you'll work four 10-hour shifts each week , providing an additional day off during the week. Team members are expected to work every other weekend as part of the regular rotation. Available shift options include: 10:00 a.m. - 8:00 p.m. 12:00 p.m. - 10:00 p.m. (eligible for a 10% shift differential) ​We are seeking candidates who are flexible and comfortable working either shift based on business needs. We value work-life balance and strive to create schedules that support both team collaboration and operational excellence. Benefits & Additional Compensation In addition to our comprehensive benefits package, this role offers premium pay opportunities: 10% weekend differential for hours worked on weekends. 10% shift differential for hours worked during the 12:00 p.m. - 10:00 p.m. shift . These differentials compound , meaning team members working the 12:00 p.m. - 10:00 p.m. shift on a weekend may receive a total 20% differential for eligible hours worked. Essential job function include: Resource Utilization Utilizes proactive triggers (diagnoses, cost criteria, and complications) to identify potential over/under utilization of services Initiates appropriate referral to physician advisor in a timely manner Understands proper utilization of health care resources and assists with identifying barriers to patient progress and collaborates with the interdisciplinary team Collaborates with financial clearance center, patient access, financial counselors and/or business office regarding billing issues related to third party payers Medical Necessity Determination Conducts medical necessity review of all admissions. Utilizes approved clinical review criteria to determine medical necessity for admissions including appropriate patient status and continued stay reviews, possibly from an offsite location Provides inpatient and observation (if indicated) clinical reviews for commercial carriers to the Financial Clearance Center (FCC) within one business day of admission Communicates all medical necessity review outcomes to in-house care management staff and relevant parties as needed Collaborates with the in-house staff and/or physician to clarify information, obtain needed documentation, present opportunities and educate regarding appropriate level of care Collaborates with the financial clearance center, patient access, financial counselors, and/or business office regarding billing issues related to third party payers Denial Management Coordinates the P2P process with the physician or physician advisor, FCC, Revenue Cycle team when necessary and when assigned and maintains documentation relevant to the appeal process. Maintains appropriate information on file to minimize denial rate Assist in recording denial updates; overturned days and monitor and report denial trends that are noted Monitor for readmissions Quality/Revenue Integrity Demonstrates active collaboration with other members of the health care team to achieve the outcomes management goals including CMS indicators Accurately records data for statistical entry and submits information within required time frame Responsible for ConnectCare and ADT work queues assigned to VUR for revenue cycle workflow Accurately records data for statistical entry and submits information within required time frame Documentation will reflect all work and communication related to the FCC, payor, physician, physician advisor and in-house care management Second-level physician reviews will be sent as required and responses/actions reflected in documentation Facilitation of Patient Care Prioritizes patient reviews based on situational analysis, functional assessment, medical record review, and application of clinical review criteria Collaborates with the in-h