Remote Senior Virtual Utilization Review Specialist

Ensemble

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Full time
Posted Yesterday
R018162

Thank you for considering a career at Ensemble Health Partners!

 

Ensemble Health Partners 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

 

 

 

 

The Opportunity:

 

 

Essential Functions (7-10) Statements – List the essential functions of the job. Essential functions are the reasons a job exists.

Resource Utilization

____ 1.Utilizes proactive triggers (diagnoses, cost criteria, and complications) to identify potential over/under utilization of services.

____ 2.Initiates appropriate referral to physician advisor in a timely manner.

____ 3.Understands proper utilization of health care resources and assists with identifying barriers to patient progress and collaborates with hospital liaison.

____ 4.Collaborates with financial clearance center, patient access, financial counselors and/or business office regarding billing issues related to third party payers.

Medical Necessity Determination

____ 5.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.

____ 6.Provides inpatient and observation (if indicated) clinical reviews for commercial carriers to the Financial Clearance Center within one business day of admission.

____ 7.Communicates all medical necessity review outcomes to hospital liaison.

____ 8.Collaborates with the liaison to clarify information, obtain needed documentation, present opportunities and educate regarding appropriate level of care.

____ 9.Collaborates with the financial clearance center, patient access, financial counselors, and/or business office regarding billing issues related to third party payers.

Denial Management

____ 10.Coordinates the appeal process with the liaison, Financial Clearance Center, Revenue Cycle team when necessary and when assigned and maintains documentation relevant to the appeal process.

____ 11.Maintains appropriate information on file to minimize denial rate.

____ 12.Assist in recording denial updates; overturned days and monitor and report denial trends that are noted.

____ 13.Monitor for readmissions and report possibilities for readmission and current readmissions to the liaison.

Discharge Planning

____ 10.Through the medical record review, evaluates for discharge planning needs of patients and makes appropriate and timely referrals to the care team and/or liaison, in order to ensure a timely discharge and to provide appropriate linkage with post discharge care providers.

 

Quality/Revenue Integrity

____ 10.Demonstrates active collaboration with other members of the health care team to achieve the outcomes management goals including CMS indicators.

____ 11.Accurately records data for statistical entry and submits information within required time frame.

____ 12.Responsible for ConnectCare and ADT work queues assigned to case management for revenue cycle workflow.

____ 13.Accurately records data for statistical entry and submits information within required time frame.

____ 14.Documentation will reflect all work and communication related to the Financial Clearance Center and hospital-based liaison.

____ 15.Second-level physician reviews will be sent as required and responses/actions reflected in documentation.

 

Facilitation of Patient Care

____ 10.Prioritizes patient care needs based on situational analysis, functional assessment, medical record review, and application of clinical review criteria.

____ 11.Collaborates with the liaison in developing and expanding the plan of care to encompass multidisciplinary patient care needs.

____ 12.Maintains rapport and communication with the liaison to monitor and evaluate the plan of care. Identifies variances in plan and makes adjustments as required to ensure continuity of care. Collaborates with the liaison to direct care towards predictable outcomes.

____ 13.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

____ 10.Directs physician and patient communication regarding non-coverage of benefits to the liaison.

____ 11.Maintains positive, open communication with the physicians, nurses, multidisciplinary team members, liaison and administration.

____ 12.Educates hospital and medical staff regarding case management program.

____ 13.Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis.

____ 14.Voicemail will be utilized and answered in timely fashion. Hospital provided communication devices will be use during work hours.

____ 15.Staff is expected to respond and/or acknowledge communication from the Financial Clearance Center via approved communication guidelines and standardized service-line agreements.

____ 16.Staff must be available as designated for meetings or training unless prior arrangements are made.

 

Team Affirmation

____ 10.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.

____ 11.Actively participates in departmental process improvement team; planning, implementation, and evaluation of activities.

____ 12.Provides back-up support to other departmental staff as needed.

 

IV.       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 (i.e., medical necessity criteria, MS-DRGs, POA). Actively participates in departmental meetings and activities. Participates in hospital and community committees as assigned. Actively participates in conferences, committees, and task forces as directed by the case management division. Performs other duties as assigned.

 

Join an award-winning company

 

Three-time winner of “Best in KLAS” 2020-2022

2022 Top Workplaces Healthcare Industry Award

2022 Top Workplaces USA Award

2022 Top Workplaces Culture Excellence Awards

  • 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 Health Partners 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 Health Partners also prohibits harassment of applicants or employees based on any of these protected categories.

 

Ensemble Health Partners 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 TA@ensemblehp.com.