[Hiring] Utilization Review RN @Ensemble Health Partners

Role 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!

Qualifications

• Bachelor's Degree or equivalent experience; Specialty/Major: Nursing or related field
• Current unrestricted 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

Requirements

• Must have current compact RN license, or be willing to obtain
• NICU and/or Pediatric nursing experience is strongly preferred
• Experience caring for neonatal, infant, and pediatric patient populations
• Flexible and comfortable working either shift based on business needs
• Access to high-speed internet for remote work
• Willingness to travel to and work onsite at client, temporary, or corporate office locations as business needs require

Benefits

• Bonus Incentives
• Shift Differentials
• Paid Certifications
• Tuition Reimbursement
• Comprehensive Benefits
• Career Advancement
• Salary Range: $63,100 - $94,650 annually, dependent upon experience, education, certifications, and overall qualifications
• 10% weekend differential for hours worked on weekends
• 10% shift differential for hours worked during the 12:00 p.m. - 10:00 p.m. shift

Essential Job Functions

• 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 when assigned
  • 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
  • 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 of the principles of growth and development of the life span
  • Possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements
• 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
  • Utilizes voicemail, Skype, and email in a timely fashion
• 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
  • Actively participates in conferences, committees, and task forces as directed by the FCC division

Other Knowledge, Skills, and Abilities Required

• Excellent interpersonal, communication and negotiation skills in interactions with physicians, payors, and health care team colleagues
• Commitment to exceptional customer service at all times
• Strong clinical assessment, organization and problem-solving skills
• Ability to prioritize, organize information, and complete multiple tasks effectively in a fast-paced environment
• Resourceful and able to work independently
• Must be inquisitive and demonstrate openness to innovation including AI