Virtual Utilization Review Specialist – Remote Jobs in United States at Ensemble Health Partners

Title: Virtual Utilization Review Specialist – Remote

Company: Ensemble Health Partners

Location: United States

Thank you for considering a career at Ensemble Health Partners!The Virtual Utilization Review (VUR) is a key contributor to the overall financial, quality, and clinical performance of the organization. The VUR supports an outcomes-oriented, patient care delivery system, which places the patient at the center of all activities.

The VUR facilitates the improvement of overall quality and completeness of medical record documentation. The VUR provides a positive financial impact to the institution through extensive interaction with physicians, nurses, other patient care givers, and coding professionals to ensure that medical record documentation accurately reflects the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete. Monitors and evaluates care to ensure costs are medically necessary, provided in the appropriate setting, and are generated according to governmental and regulatory agency standards.

Essential Job FunctionsResource 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 requi…

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