Sr. Virtual Utilization Review Specialist

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.

About the role

We are seeking Virtual Utilization Review Specialists to join our team. This remote role focuses on resource utilization, medical necessity determination, denial management, quality/revenue integrity, and facilitation of patient care.

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; 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 using approved clinical review criteria to determine medical necessity for admissions, including appropriate patient status and continued stay reviews
  • Provides inpatient and observation 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 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 peer-to-peer (P2P) process with the physician or physician advisor, FCC, Revenue Cycle team when necessary and maintains documentation relevant to the appeal process
  • Maintains appropriate information on file to minimize denial rate
  • Assists in recording denial updates, overturned days, and monitors and reports denial trends
  • Monitors for readmissions
• Quality/Revenue Integrity
  • Demonstrates active collaboration with other members of the health care team to achieve 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 Virtual Utilization Review (VUR) for revenue cycle workflow
  • Documentation reflects all work and communication related to the FCC, payor, physician, physician advisor, and in-house care management
  • Second-level physician reviews are sent as required and responses/actions are 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 knowledge and skills necessary to provide care appropriate to the age of patients served
  • Demonstrates knowledge of the principles of growth and development of the life span and assesses data reflective of the patient's status to interpret appropriate information needed for patient care
• Communication
  • Directs physician and patient communication regarding non-coverage of benefits
  • Maintains positive, open communication with 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 conflict or crisis situations
  • Voicemail, Skype, and email are utilized and answered in a timely fashion; hospital-provided communication devices are used during work hours
  • Responds and/or acknowledges communication from the FCC via approved communication guidelines and standardized service-line agreements
  • Available for meetings or training, onsite or online, unless prior arrangements are made
• Team Affirmation
  • Works collaboratively with peers to achieve departmental goals through respectful and clear communication
  • Sensitive to workload of peers; shares responsibilities, fills in, and offers help
  • Actively participates in departmental process improvement teams, including planning, implementation, and evaluation
  • Provides back-up support to other departmental staff as needed
• Other Job Functions
  • Complies with FCC and department policies and procedures, including confidentiality and patient’s rights
  • Maintains clinical competency and current knowledge of regulatory and payer requirements (e.g., 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
  • May perform other job-related duties as required by supervisor, subject to reasonable accommodation

Requirements

• Current unrestricted LPN or RN compact license (RN preferred)
• Available to work Monday - Friday, 8am - 5pm Central Time and every other weekend

Qualifications

• Bachelor's Degree or equivalent experience; Nursing or related field
• Three years nursing experience in an acute care environment preferred
• Utilization review/discharge planning experience preferred
• Recent experience or working knowledge of medical necessity review criteria preferred
• Current working knowledge of quality improvement processes

Skills

• Remote role requiring access to high-speed internet
• Excellent interpersonal, communication, and negotiation skills in interactions with physicians, payors, and healthcare team colleagues
• Commitment to exceptional customer service
• Strong clinical assessment, organization, and problem-solving skills
• Ability to assess and identify appropriate resources, work collaboratively with healthcare teams, providers, and payors
• Ability to prioritize, organize information, and complete multiple tasks effectively in a fast-paced environment
• Resourceful and able to work independently
• Inquisitive and open to innovation, including AI, to improve processes and patient/client experiences
• Willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require

Benefits

• Bonus Incentives
• Paid Certifications
• Tuition Reimbursement
• Comprehensive Benefits
• Career Advancement

Pay

• RN pay scale: $39.40 - $53/hr based on experience
• LPN pay scale: $32.65 - $46.90/hr based on experience

Schedule

Monday - Friday, 8am - 5pm Central Time and every other weekend

About Ensemble

Ensemble is an award-winning company recognized for excellence in revenue cycle management:

• 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)

Ensemble values include:

• O.N.E Purpose:
  • Customer Obsession: Exceptional experiences for clients, patients, and colleagues
  • Embracing New Ideas: Innovation through emerging technology and creativity
  • Striving for Excellence: High-level execution and outstanding results
• Associate Benefits: Comprehensive benefits package supporting physical, emotional, and financial health
• Culture: People-first environment rooted in collaboration, growth, and innovation
• Growth: Investment in professional development, including certifications and tuition reimbursement
• Recognition: Quarterly and annual incentive programs