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Utilization Review Supervisor
Ensemble Health Partners. Identify potential over/under utilization using diagnoses, cost criteria, and complications .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Review and Clinical Assessment, with a strong focus on Medical Necessity Reviews and Denial Management. Proven ability to collaborate effectively with multidisciplinary teams and communicate outcomes to enhance patient care and operational efficiency.
Highest-signal resume keywords
Utilization Review ExperienceClinical Assessment SkillsRN LicenseLeadership 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
Medical Necessity ReviewDenial ManagementStatistical Data RecordingDatabase AnalysisSpreadsheet AnalysisPatient Care CoordinationDischarge PlanningQuality ImprovementDocumentation ComplianceProblem-Solving Skills
Soft Skills
Effective CommunicationCollaborationOrganizationPrioritizationCoaching Skills
Certifications & Qualifications
RN LicenseMCG Certification
Industry Keywords
Acute CarePatient RightsRegulatory ComplianceCMS IndicatorsHealthcare TeamsCare CoordinationMultidisciplinary TeamsQuality Integrity GoalsDenial TrendsCase Management
About the role
Key responsibilities & impact- Identify potential over/under utilization using diagnoses, cost criteria, and complications
- Refer cases to the physician advisor and identify barriers to patient progress
- Conduct daily medical necessity reviews for admissions, patient status, and continued stays
- Provide inpatient and observation clinical reviews for commercial carriers within one business day of admission
- Communicate review outcomes and collaborate with hospital liaisons on documentation, level of care, and education
- Coordinate denial appeals and maintain documentation to minimize denial rates
- Track denial updates, overturned days, readmission possibilities, and denial trends
- Support quality and revenue integrity goals, including CMS indicators and case-management work queues
- Record and submit statistical data within required timeframes
- Facilitate multidisciplinary patient care plans and continuity of care
- Communicate with physicians, nurses, multidisciplinary teams, liaisons, and administration
- Educate hospital and medical staff about the case management program
- Participate in process-improvement teams, departmental meetings, committees, conferences, and task forces
- Provide backup support to departmental staff and comply with confidentiality, patient-rights, regulatory, and payer requirements
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 experience preferred
- Effective verbal and written communication skills
- Ability to collaborate with all members of the care team
- Strong clinical assessment, organization, and problem-solving skills
- Ability to identify appropriate internal and community resources and work collaboratively with healthcare teams, providers, and payors
- Ability to organize information quickly, prioritize, and complete multiple tasks
- Strong technical skills including database and spreadsheet analysis
- Associates degree in Nursing required
- Bachelors degree in Nursing preferred
- Current MCG certification or willingness to obtain within 6 months of hire
- Must reside and be authorized to work within the United States
Benefits
Comp & perks- Bonus Incentives
- Paid Certifications
- Tuition Reimbursement
- Comprehensive Benefits, including healthcare, time off, retirement, and well-being programs
- Career Advancement
- Professional development
- Quarterly and annual incentive programs
- Work-Life Flexibility
- Remote work