Utilization Review Manager

Praxy; Northern (KY); Remote; USD 92,000 - 139,000; Full time

Benefits offered by this job

Bonus incentives

Paid certifications

Tuition reimbursement

Comprehensive benefits

Career advancement

Job summary

Ensemble is seeking a Manager for Utilization Review to lead the centralized Virtual Utilization Management Program. You will guide authorization, denials, and appeals for inpatient, observation, and outpatient cases, collaborating with risk, coding, and care management teams.

Requires a nursing license and an associate degree, with a certification (MCG) due within six months. This remote role may require travel to client sites or corporate offices as needed, and offers strong growth in a

Qualifications

• 2 Year/Associates Degree Nursing or higher is required.
• Current unrestricted nursing license in the resident state is required.
• MCG Certification must be obtained within 6 months of hire.

Responsibilities

• Develops and manages the Medical Management department activities to meet department and corporate targets and goals.
• Based upon strategic initiatives and departmental goals develops a UM work plan annually and reports completed activities to the Director of the Financial Clearance Center, VP for Revenue Cycle Services and the Corporate Director of Care Management services for BSHSI.
• Oversees operational activities of the Virtual UM staff and provides direct support to Care Coordination to improve LOS and excess days.
• Participates on committees and conducts studies to demonstrate improvement in Denial/Appeal processes.
• Monitors and evaluates UM staffing productivity and effectiveness.
• Manages UM staff to decrease IP/OBV denials and improve appeal outcomes.
• Collaborates with facility-based Care Coordination to maximize appropriate level of care and decrease LOS.

Education

2 Year/ Associates Degree Nursing

Job description

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
• Paid Certifications
• Tuition Reimbursement
• Comprehensive Benefits
• Career Advancement
• This position pays between $92,400 - $138,600 based on experience

By embodying our core purpose of customer obsession, new ideas, and driving innovation, and delivering excellence, you will help ensure that every touchpoint is meaningful and contributes to our mission of redefining the possible in healthcare.

The Manager for Utilization Review is responsible for the leadership and management of the centralized Virtual Utilization Management Program and maintaining the support structure within the department for achieving clinical and operational excellence, expected deliverables of the Program in relation to UM efforts, to include the authorization, denials and appeals of inpatient and observation or outpatients. The Manager will also assume the system program compliance, program development and strategy responsibilities in collaboration with the Managers of Bedded Insurance Authorization, Pre-Authorization Diagnostic, Pre-Registration and Surgical Authorization. The Manager for Utilization Review is also responsible for collaboration with the local market hospital-based UM leaders and physician advisors in addition to: Coding, Care Coordination, Clinical Documentation Specialists and Health Information Management. Collaborates extensively with other members of the health care team to provide data and solution development processes.

Decision Making - Makes decisions by gathering, analyzing, and interpreting information; chooses the best course of action by establishing clear decision criteria, generating and evaluating alternatives, and making timely decisions.Courage - Proactively confronts difficult issues and effectively participates in challenging conversations; makes hard choices and takes bold action in the face of opposition or fear. Refuses defeat.Influencing - Uses effective persuasion techniques to gain acceptance of ideas and commitment to actions that support specific outcomes.Coaching & Developing Others - Partners with individuals’ and supports their development of knowledge, skills, and abilities; empowers them to unlock their potential and maximize performance and growth knowing that developing you makes us better.Emotional Intelligence - Establishes and sustains trusting relationships by accurately understanding and interpreting one’s own and others’ emotions and adapts behaviors to accomplish intended results.Creating an Inclusive Environment - Makes decisions and initiates action to ensure that policies and business practices leverage the capabilities and insights of individuals with diverse backgrounds, cultures, styles, abilities, and motivation.

Essential Job Functions:

Develops and manages the Medical Management department activities to meet department and corporate targets and goals.

Based upon strategic initiatives and departmental goals develops a UM work plan annually and report completed activities to the Director of the Financial Clearance Center, VP for Revenue Cycle Services and the Corporate Director of Care Management services for BSHSI. Oversees operational activities of the Virtual UM staff. Provide direct support and resources to Care Coordination to effectively improve LOS and excess days. Provide indirect support to CDS Director to manage and oversee the operational effectiveness of Clinical Documentation department. Participates on committees and conducts studies as necessary to demonstrate improvement in Denial/Appeal processes.

• Proficient in negotiating complex systems to effect positive change.
• Must possess skills required to run a fiscally responsible program while ensuring constant improvement.
• Actively involved in process redesign to eliminate excess days and decrease overall length of stay for inpatients.
• Tracks and trends program compliance. Collaborates with interdisciplinary teams including, but not limited to, physicians, nurse practitioners, PA's, and the department managers for Revenue.

Monitors and evaluates UM staffing productivity and effectiveness.

• Manages UM (Denial/Appeal) staff to decrease number of IP/OBV denials, improve appeal outcomes and address issues resulting in failed bill report.
• Collaborates with facility-based Care Coordination staff to maximize appropriate level of care and decrease length of stay.
• Proficient in communicating clearly and effectively with multiple constituents.
• Proficient on computer usage, esp. database and spreadsheet analysis.

Review the department program to ensure compliance to state and regulatory guidelines.

• Broad knowledge and skilled use of MCG or nursing criteria guidelines.
• Broad knowledge of insurance regulations and Medicare and Medicaid guidelines.

Identify staff development opportunities and evaluation tasks for UM staff.

• Ownership of UM staff annual employee engagement with active action plan to address issues.

Develop departmental budget with Director of Utilization Management and AVP of Utilization Management. Accountable for meeting and managing departmental goals and budgets. Negotiates for budgetary dollars FTE's necessary to support business initiatives for department sections’ future growth when needed.

• Review monthly department budget reports, UM and design action plan to address budget variances.
• Other duties as assigned.

Experience We Love:

• Demonstrated advanced usage of AI and the management of teams using AI to lean in to process and technological improvements, to include the exploration, experimentation, and application of AI.
• This is a remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require.

Required Minimum Education:

• 2 Year/ Associates Degree Nursing / Preferred Education: 4 year/ Bachelors Degree Nursing

Required License:

• Current unrestricted license to practice nursing in the resident State

Required Certification:

• MCG Certification required within 6 months of hire

Join an award-winning company

• Five-time winner of "Best in KLAS" 2020-2022, 2024-2025
• Black Book Research's Top Revenue Cycle Management Outsourcing Solution 2021-2024
• 22 Healthcare Financial Management Association (HFMA) MAP Awards for High Performance in Revenue Cycle 2019-2024
• Leader in Everest Group's RCM Operations PEAK Matrix Assessment 2024
• Clarivate Healthcare Business Insights (HBI) Revenue Cycle Awards for strong performance 2020, 2022-2023
• Fortune Media Best Workplaces in Healthcare 2024
• Monster Top Workplace for Remote Work 2024
• Great Place to Work certified 2023-2024

Bottom line, we believe in empowering people and giving them the tools and resources needed to thrive. A few of those include:

• Associate Benefits – We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.
• Our Culture – Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.
• Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.
• Recognition – We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company.

Ensemble is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national origin, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws. Ensemble also prohibits harassment of applicants or employees based on any of these protected categories.

Due to business, operational, payroll, and regulatory requirements, this position is limited to individuals who reside and are authorized to work within the United States. Applications generated from outside the United States will not be considered. Individuals may reapply when located within the United States.

Ensemble provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require accommodation in the application process, please contact [e-mail].

This posting addresses state specific requirements to provide pay transparency. Compensation decisions consider many job-related factors, including but not limited to geographic location; knowledge; skills; relevant experience; education; licensure; internal equity; time in position. A candidate entry rate of pay does not typically fall at the minimum or maximum of the role’s range.