Virtual Utilization Review Manager

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

The Manager for Utilization Review is responsible for the leadership and management of the centralized BSHSI Virtual Utilization Management Program and maintaining the support structure within the department for achieving clinical and operational excellence. This includes expected deliverables of the Program in relation to UM efforts, such as the authorization, denials, and appeals of inpatient and observation or outpatients.

The Manager will also assume system program compliance, program development, and strategy responsibilities in collaboration with the Managers of Bedded Insurance Authorization, Pre-Authorization Diagnostic, Pre-Registration, and Surgical Authorization. This role involves collaboration with local market hospital-based UM leaders, physician advisors, Coding, Care Coordination, Clinical Documentation Specialists, and Health Information Management. The Manager will work extensively with other members of the healthcare team to provide data and solution development processes.

Responsibilities

• Develops and manages the Medical Management department activities to meet department and corporate targets and goals.
• Creates an annual UM work plan based on strategic initiatives and departmental goals, reporting completed activities to leadership.
• Oversees operational activities of the Virtual UM staff.
• Provides direct support and resources to Care Coordination to improve length of stay (LOS) and reduce excess days.
• Provides indirect support to the CDS Director to manage and oversee the operational effectiveness of the Clinical Documentation department.
• Participates in committees and conducts studies to demonstrate improvement in Denial/Appeal processes.
• Negotiates complex systems to effect positive change and runs a fiscally responsible program while ensuring constant improvement.
• Actively involved in process redesign to eliminate excess days and decrease overall inpatient length of stay.
• Tracks and trends program compliance.
• Collaborates with interdisciplinary teams, including physicians, nurse practitioners, PAs, and department managers for Revenue.
• Monitors and evaluates UM staffing productivity and effectiveness.
• Manages UM (Denial/Appeal) staff to decrease IP/OBV denials, improve appeal outcomes, and address issues resulting in failed bill reports.
• Collaborates with facility-based Care Coordination staff to maximize appropriate level of care and decrease length of stay.
• Communicates clearly and effectively with multiple constituents.
• Proficient in computer usage, especially database and spreadsheet analysis.
• Reviews the department program to ensure compliance with state and regulatory guidelines.
• Identifies staff development opportunities and evaluation tasks for UM staff.
• Owns UM staff annual employee engagement with an active action plan to address issues.
• Develops departmental budget with Director of Utilization Management and AVP of Utilization Management.
• Accountable for meeting and managing departmental goals and budgets.
• Negotiates for budgetary dollars and FTEs necessary to support business initiatives for department sections’ future growth.
• Reviews monthly department budget reports and designs action plans to address budget variances.
• Other duties as assigned.

Job Competencies

• Decision Making: Makes decisions by gathering, analyzing, and interpreting information; chooses the best course of action by establishing clear decision criteria, generating and evaluating alternatives, and making timely decisions.
• Courage: Proactively confronts difficult issues and effectively participates in challenging conversations; makes hard choices and takes bold action in the face of opposition or fear.
• Influencing: Uses effective persuasion techniques to gain acceptance of ideas and commitment to actions that support specific outcomes.
• Coaching & Developing Others: Partners with individuals and supports their development of knowledge, skills, and abilities; empowers them to unlock their potential and maximize performance and growth.
• Emotional Intelligence: Establishes and sustains trusting relationships by accurately understanding and interpreting one’s own and others’ emotions and adapts behaviors to accomplish intended results.
• Creating an Inclusive Environment: Makes decisions and initiates action to ensure that policies and business practices leverage the capabilities and insights of individuals with diverse backgrounds, cultures, styles, abilities, and motivation.

Qualifications

• Required Minimum Education: 2-Year/Associate’s Degree in Nursing.
• Preferred Education: 4-Year/Bachelor’s Degree in Nursing.
• Required License: Current unrestricted license to practice nursing in the resident State.
• Required Certification: MCG Certification required within 6 months of hire.

Experience

• Broad knowledge and skilled use of MCG or nursing criteria guidelines.
• Broad knowledge of insurance regulations and Medicare and Medicaid guidelines.
• Demonstrated advanced usage of AI and the management of teams using AI to lean into process and technological improvements, including exploration, experimentation, and application of AI.

Benefits

• Bonus Incentives
• Paid Certifications
• Tuition Reimbursement
• Comprehensive Benefits
• Career Advancement
• Associate Benefits – Comprehensive benefits package supporting physical, emotional, and financial health, including healthcare, time off, retirement, and well-being programs.
• Culture rooted in collaboration, growth, and innovation.
• Professional development through certifications and tuition reimbursement.
• Recognition through quarterly and annual incentive programs.

Pay

This position pays between $92,400 – $138,600 based on experience.

Schedule

This is a remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require.