Senior RN, Utilization Review Quality

Ensemble Health Partners

. Review and ensure the quality of VUR team work in partnership with the Leadership Team .

Posted 10/21/2026full-timeUnited StatesSenior💰 $47 - $63 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Quality Assurance processes, including conducting audits and root cause analysis, while ensuring compliance with medical necessity and clinical documentation standards. Proven ability to mentor and train team members, assess operational risks, and present actionable recommendations to leadership.

Highest-signal resume keywords

RN LicenseQuality Improvement ProcessesUtilization Review ExperienceClinical Assessment SkillsInterpersonal Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Quality AssuranceRoot Cause AnalysisAccount ReviewsCompliance MeasurementOperational Risk IdentificationClinical DocumentationMedical Necessity ReviewAudit Findings AnalysisPolicy ImplementationTraining and Mentoring

Soft Skills

Problem-Solving SkillsOrganizational SkillsNegotiation SkillsCustomer Service CommitmentCollaboration Skills

Certifications & Qualifications

Bachelor's DegreeRN Compact License

Industry Keywords

HealthcareRevenue CycleAcute Care EnvironmentDischarge PlanningClinical ProtocolsHealthcare TeamsPayorsOperational EfficiencyRegulatory ComplianceQuality Assurance Audits

About the role

Key responsibilities & impact

Review and ensure the quality of VUR team work in partnership with the Leadership Team
Perform independent account reviews of cases handled by entry-level and senior Revenue Cycle team members
Identify improvement opportunities and make recommendations to operational and executive leaders
Support continued training, education, and ongoing action plans
Provide onboarding support, including user provisioning
Mentor UR Quality Specialists and UR team members
Assess the Quality Assurance process and identify efficiency improvements
Evaluate VUR policies and procedures and provide input into annual review workplans
Perform quality reviews across multiple clients and host systems
Conduct root cause analysis on audit findings, quality assurance audits, and utilization management denials
Coordinate with service line leaders and senior Leadership to identify risks and develop quarterly/annual review plans
Document business processes and maintain knowledge of VUR processes, protocols, and best practices
Perform account-level reviews to confirm implementation and effectiveness of policies and procedures
Measure compliance with policies, procedures, workflow, and applicable requirements
Identify and document operational, compliance, and quality risks and recommend mitigations
Prepare and present quality reports and recommendations to leadership
Participate in pre- and post-review meetings
Ensure previous review recommendations are implemented
Maintain current knowledge of laws and regulations related to medical necessity, clinical documentation, compliance, and clinical/business matters

Requirements

What you’ll need

Bachelor's Degree or equivalent experience; Specialty/Major: Nursing or related field
Current unrestricted RN license required
RN compact license preferred
Three years nursing experience in an acute care environment required
Utilization review/discharge planning experience preferred
Recent experience or working knowledge of medical necessity review criteria preferred
Current working knowledge of quality improvement processes
Excellent interpersonal, communication, and negotiation skills
Commitment to exceptional customer service
Strong clinical assessment, organization, and problem-solving skills
Ability to assess and identify appropriate resources and collaborate with healthcare teams, providers, and payors
Ability to prioritize, organize information, and complete multiple tasks in a fast-paced environment
Resourceful and able to work independently
Must demonstrate openness to innovation, including AI
Must reside in and be authorized to work within the United States
Must be willing and able to work within 8:00 a.m. to 10:00 p.m. scheduled hours, including weekends as needed
Must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require

Benefits

Comp & perks

Bonus Incentives
Paid Certifications
Tuition Reimbursement
Comprehensive benefits package including healthcare, time off, retirement, and well-being programs
Professional certification relevant to the associate’s field
Quarterly and annual incentive programs
Career advancement opportunities
Work-life flexibility
Professional development and growth opportunities