Sr. Virtual Utilization Review Specialist
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:
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Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.
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Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.
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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 $32.65/hr - $43.90/hr based on experience
**Must have c urrent RN or LPN compact license**
Please note that the VUR department operates 7 days per week from 8:00 a.m. to 10:00 p.m., and candidates must be willing and able to work within these scheduled hours, including weekends as needed.
We are seeking Virtual Utilization Review Specialists to join our team.
Essential job function include:
Resource Utilization
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Utilizes proactive triggers (diagnoses, cost criteria, and complications) to identify potential over/under utilization of services
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Initiates appropriate referral to physician advisor in a timely manner
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Understands proper utilization of health care resources and assists with identifying barriers to patient progress and collaborates with the interdisciplinary team
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Collaborates with financial clearance center, patient access, financial counselors and/or business office regarding billing issues related to third party payers
Medical Necessity Determination
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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
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Provides inpatient and observation (if indicated) clinical reviews for commercial carriers to the Financial Clearance Center (FCC) within one business day of admission
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Communicates all medical necessity review outcomes to in-house care management staff and relevant parties as needed
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Collaborates with the in-house staff and/or physician to clarify information, obtain needed documentation, present opportunities and educate regarding appropriate level of care
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Collaborates with the financial clearance center, patient access, financial counselors, and/or business office regarding billing issues related to third party payers
Denial Management
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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.
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Maintains appropriate information on file to minimize denial rate
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Assist in recording denial updates; overturned days and monitor and report denial trends that are noted
- Monitor for readmissions
Quality/Revenue Integrity
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Demonstrates active collaboration with other members of the health care team to achieve the outcomes management goals including CMS indicators
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Accurately records data for statistical entry and submits information within required time frame
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Responsible for ConnectCare and ADT work queues assigned