Virtual Utilization Review Specialist - WEEKENDS

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. 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 IncentivesPaid CertificationsTuition ReimbursementComprehensive BenefitsCareer AdvancementThis position pays between $32.65 - $35.95/hr final compensation will be based on experience$$ Shift Differential for Select Shifts $$**Must haveCurrent unrestricted LPN or RN license (required) or RN compact license (preferred)**We are seeking Virtual Utilization Review Specialists who are interested in compressed, weekend work schedules. The schedules we are offering include: Work Schedule:Full-time:Friday, Saturday, Sunday: 7:00 AM - 7:00 PM with a 4 hour shift on WednesdayPart-time:Saturday and Sunday: 10 hour shift each dayResource UtilizationUtilizes proactive triggers (diagnoses, cost criteria, and complications) to identify potential over/under utilization of servicesInitiates appropriate referral to physician advisor in a timely mannerUnderstands proper utilization of health care resources and assists with identifying barriers to patient progress and collaborates with the interdisciplinary teamCollaborates with financial clearance center, patient access, financial counselors and/or business office regarding billing issues related to third party payersMedical Necessity DeterminationConducts 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 locationProvides inpatient and observation (if indicated) clinical reviews for commercial carriers to the Financial Clearance Center (FCC) within one business day of admissionCommunicates all medical necessity review outcomes to in-house care management staff and relevant parties as neededCollaborates with the in-house staff and/or physician to clarify information, obtain needed documentation, present opportunities and educate regarding appropriate level of careCollaborates with the financial clearance center, patient access, financial counselors, and/or business office regarding billing issues related to third party payersDenial ManagementCoordinates 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 processMaintains appropriate information on file to minimize denial rateAssist in recording denial updates; overturned days and monitor and report denial trends that are notedMonitor for readmissionsQuality/Revenue IntegrityDemonstrates active collaboration with other members of the health care team to achieve the outcomes management goals including CMS indicatorsAccurately records data for statistical entry and submits information within required time frameResponsible for ConnectCare and ADT work queues assigned to VUR for revenue cycle workflowAccurately records data for statistical entry and submits information within required time frameDocumentation will reflect all work and communication related to the FCC, payor, physician, physician advisor and in-house care managementSecond-level physician reviews will be sent as required and responses/actions reflected in documentationFacilitation of Patient CarePrioritizes patient reviews based on situational analysis, functional assessment, medical record review, and application of clinical review criteriaCollaborates 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 assignmentDemonstrates 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