Virtual Utilization Review Specialist - PART TIME WEEKENDS
Overview
Thank you for considering a career at Ensemble Health Partners!
Ensemble Health Partners 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 and emphasizes empowering people to challenge the status quo.
The Opportunity
CAREER OPPORTUNITY OFFERING:
- Bonus Incentives
- Paid Certifications
- Tuition Reimbursement
- Comprehensive Benefits
- Career Advancement
- This position pays between $28.90 - $35.45/hr based on experience
- Shift Differential for Select Shifts
Must have Current unrestricted LPN or RN license (required) or RN compact license (preferred).
We are seeking part time Virtual Utilization Review Specialists who are interested in compressed, weekend work schedules.
Work Schedule
- Saturday & Sunday, 1st shift, two 10-hour shifts
- Saturday & Sunday, 1st shift, two 8-hour shifts + a 4-hour shift on Monday
Resource Utilization
- Utilizes proactive triggers to identify potential over/under utilization of services
- Initiates appropriate referral to physician advisor in a timely manner
- 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 with third party payers
Medical Necessity Determination
- Conducts medical necessity review of all admissions using approved clinical criteria
- Provides inpatient/observation clinical reviews for commercial carriers within one business day of admission
- Communicates review outcomes to in-house care management staff and relevant parties
- Collaborates with in-house staff and/or physician to clarify information and educate regarding appropriate level of care
- Collaborates with FCC, payors, and business office regarding billing issues
Denial Management
- Coordinates P2P process with physician/physician advisor, FCC and Revenue Cycle team when needed
- Maintains information to minimize denial rate
- Records denial updates; monitors denial trends
- Monitors readmissions
Quality / Revenue Integrity
- Collaborates with health care team to meet CMS indicators
- Records data for statistical entry and submits on time
- Manages ConnectCare and ADT work queues for revenue cycle workflow
- Documentation reflects all work and communication with FCC, payor, physician, physician advisor and care management
- Second-level physician reviews as required
Facilitation of Patient Care
- Prioritizes patient reviews based on analysis and criteria
- Maintains rapport with in-house care manager and demonstrates age-appropriate care knowledge
- Assesses patient data to identify requirements by age and provide needed care per policies
Communication
- Directs physician and patient communication regarding non-coverage of benefits
- Maintains positive communication with physicians, nurses, and the team
- Educates hospital and medical staff about the utilization review program
- Maintains professional demeanor; responds to voicemail, Skype, and email in a timely fashion
- Uses hospital devices during work hours and follows approved communication guidelines
- Available for meetings or training as designated
Team Affirmation
- Collaborates with peers, communicates respectfully, and shares responsibilities
- Participates in process improvement and provides backup support
Other Job Functions
- Complies with policies including confidentiality and patient rights
- Maintains clinical competency and knowledge of regulatory and payer requirements (e.g., medical necessity criteria, MS-DRGs, POA)
- Participates in departmental meetings and FCC/community committees
- Performs other duties as assigned
Experience
- Bachelor’s Degree or equivalent experience; Nursing or related field preferred
- RN or LPN license required; RN compact preferred
- Five years nursing experience in an acute care environment required
- Utilization review/discharge planning experience preferred
- Knowledge of medical necessity review criteria preferred
- Knowledge of quality improvement processes preferred
Other Knowledge, Skills, and Abilities
- Ability to work a compressed weekend schedule
- Remote role requiring high-speed internet
- Excellent interpersonal, communication and negotiation skills with physicians, payors, and care team
- Commitment to exceptional customer service
- Effective verbal and written communication
- Strong clinical assessment, organization and problem-solving skills
- Ability to identify resources and work collaboratively with care team, providers, and payors
- Ability to prioritize and manage multiple tasks in a fast-paced environment
- Resourceful and able to work independently
#LI--SI1
#LI-REMOTE
Join an award-winning company
Five-time winner of “Best in KLAS” 2020-2022, 2024-2025; Black Book awards; HFMA MAP Awards; Everest Group recognition; HBI awards; Energage Top Workplaces; Fortune Best Workplaces; Monster Top Workplace; Great Place to Work
We value innovation, work-life flexibility, leadership, and purpose + values.
Benefits and Culture
- Associate Benefits – Comprehensive benefits supporting health, time off, retirement and well-being
- Our Culture – Collaborative, growth-focused environment
- Growth – Professional development and tuition reimbursement available
- Recognition – Incentive programs for performance
Ensemble Health Partners is an equal employment opportunity employer. It is our policy not to discriminate based on protected characteristics. Reasonable accommodations available upon request. Apply to TA@ensemblehp.com.
This posting includes pay transparency information. Compensation decisions consider location, experience, education, licensure, and other factors. For rights and protections, see: EEOC, FMLA, and related notices.
