Lead Utilization Review, RN

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!

• 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.

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

Pay Scale: $39.40/hr - $53/hr based on experience Please note that the UR department operates 7 days per week from 8:00 a.m. to 10:00 p.m., and candidates must be willing and able to work within these scheduled hours, including weekends as needed.

The Lead Utilization Review RN is a key contributor to the overall financial, quality, and clinical performance of the organization. The Lead UR supports an outcomes-oriented, patient care delivery system, which places the patient at the center of all activities. The Lead UR facilitates the improvement of overall quality and completeness of medical record documentation. They work to provide 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.

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. 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 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 to the within one business day of admission. Communicates all medical necessity review outcomes to hospital liaison.

Collaborates with the liaison to clarify information, obtain needed documentation, present opportunities and educate regarding appropriate level of care. Collaborates with the financial clearance center, patient…