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Utilization Review Supervisor
Ensemble Health Partners. Supervise virtual utilization review activities supporting financial, quality, and clinical performance .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Review and clinical assessment within acute care settings, ensuring compliance with medical necessity criteria and effective communication with healthcare teams. Proficient in coordinating denial appeals and facilitating multidisciplinary patient care plans to enhance quality and financial performance.
Highest-signal resume keywords
Current RN LicenseUtilization Review ExperienceClinical Assessment SkillsLeadership ExperienceMCG Certification
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ReviewMedical Necessity ReviewClinical ReviewStatistical Data SubmissionDatabase AnalysisSpreadsheet AnalysisPatient Care PlanningDenial Appeals CoordinationDocumentation ImprovementQuality Performance Monitoring
Soft Skills
Effective CommunicationCollaborative AbilityOrganizational SkillsProblem-Solving SkillsCoaching Experience
Certifications & Qualifications
Current RN LicenseMCG Certification
Industry Keywords
Acute CareHealthcare TeamsCMS IndicatorsDenial TrendsPatient Rights Policies
About the role
Key responsibilities & impact- Supervise virtual utilization review activities supporting financial, quality, and clinical performance
- Facilitate medical record documentation improvement and completeness
- Utilize proactive triggers to identify potential over- or under-utilization of services
- Refer cases to the physician advisor and identify barriers to patient progress
- Conduct daily medical necessity reviews for admissions, patient status, and continued stays
- Perform inpatient and observation clinical reviews for commercial carriers within one business day of admission
- Communicate review outcomes and collaborate with hospital liaisons on documentation, education, and level-of-care opportunities
- Coordinate denial appeals, maintain appeal documentation, monitor denial trends, and report readmissions
- Collaborate with healthcare teams to achieve outcomes management goals, including CMS indicators
- Maintain case management work queues and accurately record and submit statistical data
- Facilitate multidisciplinary patient care plans and continuity of care
- Communicate benefit non-coverage issues and educate hospital and medical staff
- Participate in process improvement teams, departmental meetings, conferences, committees, and task forces
- Provide backup support to departmental staff and comply with hospital, department, confidentiality, and patient-rights policies
Requirements
What you’ll need- 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
- Recent and working knowledge of medical necessity review criteria preferred
- Effective verbal and written communication
- Collaborative ability 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
- Ability to work collaboratively with healthcare teams, providers, and payors
- Ability to organize information, prioritize, and complete multiple tasks effectively
- Strong technical skills including database and spreadsheet analysis
- Associate's degree in Nursing required
- Bachelor's degree in Nursing preferred
- Current MCG certification or willingness to obtain within 6 months of hire
Benefits
Comp & perks- Bonus Incentives
- Paid Certifications
- Tuition Reimbursement
- Comprehensive healthcare, time off, retirement, and well-being benefits
- Career Advancement
- Professional certification relevant to the field for each associate
- Quarterly and annual incentive programs
- Work-life flexibility
- Remote work