Utilization review nurse [h1.location_city]

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 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 :

RN pay scale - on experience

LPN pay scale - on experience

• Must have Current unrestricted LPN or RN license (required) or RN compact license (preferred)

We are seeking Virtual Utilization Review Specialists to join our team.

The schedules we are offering include :

Weekday work schedule :

Essential job function 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, possibly from an offsite location

Provides inpatient and observation (if indicated) 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

Collaborates with the financial clearance center, patient access, financial counselors, and / or business office regarding billing issues related to third party payers

Denial Management

Coordinates the P2P process with the physician or physician advisor, FCC, Revenue Cycle team when necessary and when assigned and maintains documentation relevant to the appeal process.

Maintains appropriate information on file to minimize denial rate

Assist in recording denial updates; overturned days and monitor and report denial trends that are noted

Monitor 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

Accurately records data for statistical entry and submits information within required time frame

Documentation will reflect all work and communication related to the FCC, payor, physician, physician advisor and in-house care management

Second-level physician reviews will be sent as required and responses / actions reflected in documentation

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 Maintains rapport and communication with the in-house care manager Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assignment

Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to his or her age, specific needs and to provide the care needed as described in departmental policies and procedures

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.

Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis

Voicemail, Skype, and email will be utilized and answered in timely fashion. Hospital provided communication devices will be used during work hours.

Staff is expected to respond and / or acknowledge communication from the FCC via approved communication guidelines and standardized service-line agreements

Staff must be available as designated for meetings or training, onsite or online, unless prior arrangements are made

Team Affirmation

Works collaboratively with peers to achieve departmental goals in daily work as evidenced by appropriate and timely communication which is respectful and clear. Sensitive to workload of peers and shares responsibilities, fills in and offers to help

Actively participates in departmental process improvement team; planning, implementation, and evaluation of activities

Provides back-up support to other departmental staff as needed

Other Job Functions

Complies with FCC and department policies and procedure, including confidentiality and patient’s rights.

Maintains clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities medical necessity criteria, MS-DRGs, POA).

Actively participates in departmental meetings and activities.

Participates in FCC and community committees as assigned.

Actively participates in conferences, committees, and task forces as directed by the FCC division.

Associates may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation.

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 preferred

Utilization review / discharge planning experience preferred

Recent experience or working knowledge of medical necessity review criteria preferred

Current working knowledge of quality improvement processes

Other Knowledge, Skills, and Abilities Required :

This is a remote role which requires access to high speed internet

Excellent interpersonal, communication and negotiation skills in interactions with physicians, payors, and health care team colleagues

Commitment to exceptional customer service at all times

Communicate ideas and thoughts effectively verbally and in writing

Strong clinical assessment, organization and problem-solving skills

Ability to assess and identify appropriate resources, internal and community, on assigned caseload, and to work collaboratively with health care team, providers, and payors to achieve the desired patient, quality, and financial outcomes

Ability to prioritize, organize information, and complete multiple tasks effectively in a fast-paced environment

Resourceful and able to work independently

#LI-LS1

#LI-Remote

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

Energage Top Workplaces USA 2022-2024

Fortune Media Best Workplaces in Healthcare 2024

Monster Top Workplace for Remote Work 2024

Great Place to Work certified 2023-2024

Innovation

Work-Life Flexibility

Leadership

Purpose + Values

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

Ensemble Health Partners 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 Health Partners also prohibits harassment of applicants or employees based on any of these protected categories.

Ensemble Health Partners 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 .

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.

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