Utilization Review RN - Denials

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:

• Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.

• Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.

• 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 current RN compact license**

Schedule:

Monday - Friday 8:30am - 5:00pm with occasional weekend coverage

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

Essential job function include:

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

• Assist in recording denial updates; overturned days and monitor and report denial trends that are noted

• Monitor 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

• Accurately records data for statistical entry and submits information within required time frame

• 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 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. Hospital provided communication devices will be used during work hours.

• 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.

Experience:

• 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

Other Knowledge, Skills, and Abilities Required:

• 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

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Join an award-winning company

Five-time winner of “Best in KLAS” 2020-2022, 2024-2025

Black Book Research's Top Revenue Cycle Management Outsourcing Solution 2021-2024

22 Healthcare Financial Management Association (HFMA) MAP Awards for High Performance in Revenue Cycle 2019-2024

Leader in Everest Group's RCM Operations PEAK Matrix Assessment 2024

Clarivate Healthcare Business Insights (HBI) Revenue Cycle Awards for strong performance 2020, 2022-2023

Energage Top Workplaces USA 2022-2024

Fortune Media Best Workplaces in Healthcare 2024

Monster Top Workplace for Remote Work 2024

Great Place to Work certified 2023-2024

• Innovation
• Work-Life Flexibility
• Leadership
• Purpose + Values

Bottom line, we believe in empowering people and giving them the tools and resources needed to thrive. A few of those include:

• Associate Benefits –  We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs. 
• Our Culture – Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.  
• Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement. 
• Recognition – We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company. 

Ensemble is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national origin, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws.  Ensemble also prohibits harassment of applicants or employees based on any of these protected categories.

Due to business, operational, payroll, and regulatory requirements, this position is limited to individuals who reside and are authorized to work within the United States. Applications generated from outside the United States will not be considered.  Individuals may reapply when located within the United States.

Ensemble provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require accommodation in the application process, please contact [email protected].

This posting addresses state specific requirements to provide pay transparency.  Compensation decisions consider many job-related factors, including but not limited to geographic location; knowledge; skills; relevant experience; education; licensure; internal equity; time in position.  A candidate entry rate of pay does not typically fall at the minimum or maximum of the role’s range.

Employment Disclaimers – Ensemble