Virtual Utilization Review Specialist

Ensemble Health Partners; United States; Remote; USD 60,000 - 80,000; Full time

Job summary

Join a forward-thinking company as a Virtual Utilization Review Specialist, where your expertise in nursing will help ensure optimal patient care and resource utilization. This role offers a unique opportunity to work remotely while collaborating with healthcare professionals to manage patient admissions and ensure compliance with medical necessity standards. You'll play a crucial role in enhancing healthcare delivery by actively participating in quality initiatives and improving revenue integrity. If you're passionate about making a difference in healthcare and thrive in a collaborative environment, this position is perfect for you.

Qualifications

• Bachelor's degree or equivalent experience in Nursing or related field required.
• Current unrestricted LPN or RN license required.

Responsibilities

• Conduct medical necessity reviews and collaborate with healthcare teams.
• Manage denial processes and maintain communication with physicians.

Skills

Interpersonal Skills

Communication Skills

Clinical Assessment

Problem-Solving Skills

Organizational Skills

Education

Bachelor's Degree in Nursing or related field

Job description

Thank you for considering a career at Ensemble Health Partners!

Ensemble Health Partners 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!

The Opportunity:

We are seeking Virtual Utilization Review Specialists to join our team. Essential job functions 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.
• Provides inpatient and observation 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.

Denial Management

• Coordinates the P2P process with the physician or physician advisor, FCC, Revenue Cycle team when necessary and maintains documentation relevant to the appeal process.
• Maintains appropriate information on file to minimize denial rate.
• Assists in recording denial updates; overturned days and monitor and report denial trends that are noted.
• Monitors 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.

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-house care manager and maintains rapport and communication with the in-house care manager.

Communication

• Directs physician and patient communication regarding non-coverage of benefits.
• Maintains positive, open communication with the physicians, nurses, multidisciplinary team members and administration.
• Educates hospital and medical staff regarding utilization review program.

Team Affirmation

• Works collaboratively with peers to achieve departmental goals in daily work.
• Actively participates in departmental process improvement team; planning, implementation, and evaluation of activities.

Other Job Functions

• Complies with FCC and department policies and procedures, including confidentiality and patient’s rights.
• Maintains clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities.
• Participates in FCC and community committees as assigned.

Experience:

• Bachelor's Degree or equivalent experience; Specialty/Major: Nursing or related field.
• Current unrestricted LPN or RN license required; RN compact license preferred.
• Three years nursing experience in an acute care environment required.
• Utilization review/discharge planning experience preferred.

Other Knowledge, Skills, and Abilities Required:

• This is a remote role which requires access to high-speed internet.
• Excellent interpersonal, communication and negotiation skills.
• Strong clinical assessment, organization and problem-solving skills.

Join an award-winning company

Ensemble Health Partners is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee.