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! 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. The Opportunity 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 Information Our Utilization Review team provides coverage seven days a week, operating between 8:00 a.m. and 10:00 p.m. To support our patients and partners, team members are scheduled within these hours, including weekends on a rotating basis. This role follows a 4x10 schedule, meaning you'll work four 10-hour shifts each week, providing an additional day off during the week. Team members are expected to work every other weekend as part of the regular rotation. Available shift options include: 10:00 a.m. - 8:00 p.m. 12:00 p.m. - 10:00 p.m. (eligible for a 10% shift differential) We are seeking candidates who are flexible and comfortable working either shift based on business needs. We value work-life balance and strive to create schedules that support both team collaboration and operational excellence. Benefits & Additional Compensation 10% weekend differential for hours worked on weekends. 10% shift differential for hours worked during the 12:00 p.m. - 10:00 p.m. shift. These differentials compound, meaning team members working the 12:00 p.m. - 10:00 p.m. shift on a weekend may receive a total 20% differential for eligible hours worked. Essential job function include 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 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. 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 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 Assist in recording denial updates; overturned days and monitor and report denial trends that are noted Monitor 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 Responsible for ConnectCare 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 Facilitation of Patient Care 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 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 Maintains positive, open communication with the physicians, nurses, multidisciplinary team members and administration Educates hospital and medical staff regarding utilization review program. Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis Voicemail, Skype, and email will be utilized and answered in timely fashion. Hospital provided communication devices will be used during work hours. Staff is expected to respond and/or acknowledge communication from the FCC via approved communication guidelines and standardized service-line agreements Staff must be available as designated for meetings or training, onsite or online, unless prior arrangements are made Team Affiliation 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 FCC 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 FCC and community committees as assigned. Actively participates in conferences, committees, and task forces as directed by the FCC division. Associates may be required to perform other job-related duties as required by their supervisor, subject to #J-18808-Ljbffr