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.

CAREER OPPORTUNITY OFFERING:

• 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.

We are seeking Virtual Utilization Review Specialist with at least 1 year 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.
• 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.
• 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.
• Documentation – Records 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…