[Hiring] Virtual Utilization Review Supervisor @Ensemble Health Partners

Role Description

The Virtual Utilization Review Supervisor is a key contributor to the overall financial, quality, and clinical performance of the organization. The VUR Supervisor supports an outcomes-oriented, patient care delivery system, which places the patient at the center of all activities. The Supervisor facilitates the improvement of overall quality and completeness of medical record documentation. The VUR Supervisor provides a positive financial impact to the institution through extensive interaction with physicians, nurses, other patient care givers, and coding professionals to ensure that medical record documentation accurately reflects the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete. Monitors and evaluates care to ensure costs are medically necessary, provided in the appropriate setting, and are generated according to governmental and regulatory agency standards.

Job Responsibilities

• 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 hospital liaison.
• MEDICAL NECESSITY DETERMINATION: Conducts medical necessity review of all admissions daily. 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 within one business day of admission.
• DENIAL MANAGEMENT: Coordinates the appeal process with the liaison, 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.
• 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.
• FACILITATION OF PATIENT CARE: Prioritizes patient care needs based on situational analysis, functional assessment, medical record review, and application of clinical review criteria. Collaborates with the liaison in developing and expanding the plan of care to encompass multidisciplinary patient care needs.
• COMMUNICATION: Directs physician and patient communication regarding non-coverage of benefits to the liaison. Maintains positive, open communication with the physicians, nurses, multidisciplinary team members, liaison and administration.
• 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.
• OTHER JOB FUNCTIONS: Complies with hospital 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.

Qualifications

• Current unrestricted RN license is required
• 1+ year of leadership and/or coaching experience
• 2+ years UR experience
• 5+ years of nursing experience in an acute care environment required
• Experience in utilization review/discharge planning
• Recent and working knowledge of medical necessity review criteria experience preferred
• Strong clinical assessment, organization and problem solving skills
• Strong technical skills including database and spreadsheet analysis

Requirements

• Bachelor's degree in Nursing preferred; Associate's degree in Nursing required
• Current MCG certification or willingness to obtain within 6 months of hire

Benefits

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