[Hiring] Senior Virtual Utilization Review Specialist @Ensemble Health Partners

Role Description

We are seeking a Virtual Utilization Review Specialist with at least 1 year Denials Management experience to join our team.

• 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 using approved clinical review criteria.
  • 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 in-house staff and/or physician to clarify information, obtain needed documentation, 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.
  • Monitors for readmissions.
• Quality/Revenue Integrity:
  • Demonstrates active collaboration with other members of the health care team to achieve outcomes management goals.
  • 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.
  • 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 and maintains rapport and communication.
  • Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patients served.
  • Demonstrates knowledge of the principles of growth and development of the life span.
• Communication:
  • Directs physician and patient communication regarding non-coverage of benefits.
  • Maintains positive, open communication with 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.
  • Utilizes voicemail, Skype, and email in a timely fashion.
  • Responds and/or acknowledges communication from the FCC via approved communication guidelines.
  • Must be available for meetings or training, onsite or online, unless prior arrangements are made.
• Team Affirmation:
  • Works collaboratively with peers to achieve departmental goals.
  • Actively participates in departmental process improvement team.
  • Provides back-up support to other departmental staff as needed.
• 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.
  • Actively participates in departmental meetings and activities.
  • Participates in FCC and community committees as assigned.
  • May be required to perform other job-related duties as required by their supervisor.

Qualifications

• Bachelor's Degree or equivalent experience; Specialty/Major: Nursing or related field.
• Current unrestricted RN license required; RN compact license 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.

Requirements

• This is a remote role which requires access to high speed internet.
• 5+ years of acute care clinical experience.
• Minimum of 2 years of utilization review experience.
• At least 1 year of denial management experience.
• Demonstrated proficiency with both InterQual and MCG criteria.
• Strong critical thinking, clinical judgment, and ability to work independently.
• Required experience with Epic EMR; experience with additional EMR systems is preferred.
• Excellent written and verbal communication skills.
• Strong technical aptitude with the ability to quickly learn, adapt to, and effectively utilize new healthcare technologies and software applications.
• Proven ability to manage multiple priorities, maintain organization, and meet deadlines in a fast-paced environment.
• Strong time management and workload prioritization skills.
• Ability to collaborate effectively within a multidisciplinary team while maintaining accountability for individual responsibilities.
• Strong understanding of CMS guidelines and their application in clinical review processes.
• Must be inquisitive and demonstrate openness to innovation including 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.

Benefits

• Bonus Incentives.
• Paid Certifications.
• Tuition Reimbursement.
• Comprehensive Benefits.
• Career Advancement.