[Hiring] Utilization Review RN - Denials @Ensemble Health Partners

Role Description

We are seeking a Virtual Utilization Review Specialist with at least 1 year of 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.
  • 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.
  • 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 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.
  • 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 (i.e., 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.

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 to explore better processes and ways to alleviate friction and improve patient and client experiences.
• 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.
• 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.
• Must have current compact RN license, or be willing to obtain.
• Schedule: Monday - Friday 8:30am - 5:00pm with occasional weekend coverage.