Sr. Virtual Utilization Review Specialist - 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!

• 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

This position pays between $32.65/hr- $43.90/hr based on experience

** Must have c
** urrent RN compact license****

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

Essential job function include:

• 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

• 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

• 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

• 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 Connect Care 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

• 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…