Lead Utilization Review, RN

About Ensemble 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! Core Purpose & Values 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. Work Details & Compensation Pay Scale: $39.40/hr - $53/hr based on experience. 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. Benefits & Incentives: Bonus Incentives, Paid Certifications, Tuition Reimbursement, Comprehensive Benefits, Career Advancement. Position Overview 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. Job Responsibilities 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 access, financial counselors, and/or business office regarding billing issues related to third party payers. DENIAL MANAGEMENT: 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. 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 and report possibilities for readmission and current readmissions to the liaison. DISCHARGE PLANNING: 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: 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 case management 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 Financial Clearance Center and hospital-based liaison. Second-level physician reviews will be sent as required and responses/actions reflected in documentation. FACILITATION OF PATIENT CARE: Prioritizes patient care needs based on situational analysis, functional assessment, medical record review, and application of clinical review criteria. Collaborates with the liaison in developing and expanding the plan of care to encompass multidisciplinary patient care needs. 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. 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 to the liaison. Maintains positive, open communication with the physicians, nurses, multidisciplinary team members, liaison and administration. Educates hospital and medical staff regarding case management program. Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis. Voicemail will be utilized and answered in timely fashion. Hospital provided communication devices will be used during work hours. Staff must be available as designated for meetings or training 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 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. Other duties as assigned. Experience & Qualifications Experience: Current unrestricted RN license is required. 5+ years of nursing experience in an acute care environment required. Experience in utilization review/ discharge planning. Recent and working knowledge of medical necessity review criteria experience preferred. Communicate ideas and thoughts effectively verbally and in written form. Able to participate collaboratively with all members of care team. Strong clinical assessment, organization and problem solving skills. Ability to assess and identify appropriate resources, internal and community, on assigned caseload and to work collaboratively with health care team, providers, and payors to achieve the desired patient, quality, and financial outcomes. Ability to organize information quickly and effectively; prioritize and complete multiple tasks effectively. Strong technical skills including database and spreadsheet analysis. Minimum Education: Bachelors degree in Nursing preferred. Associates degree Nursing required. Recruitment & Application Notes 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 View email address on click.appcast.io. Awards & Recognitions 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 Company Culture & Benefits 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. Equal Opportunity & Diversity Statement 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. #J-18808-Ljbffr Ensemble Health Partners