Virtual Utilization Review Specialist

📋 Description

• • As a Virtual Utilization Review Specialist at Ensemble Health Partners, you will play a critical role in ensuring the efficient and appropriate use of healthcare resources, directly contributing to the financial health of hospitals and the well-being of patients.
• • This position is pivotal in navigating the complexities of healthcare revenue cycle management, focusing on proactive identification of potential over or underutilization of services through the application of established clinical review criteria.
• • You will be responsible for conducting thorough medical necessity reviews for all admissions, determining the appropriate patient status and continued stay requirements, adhering strictly to approved clinical guidelines.
• • A key aspect of your role will involve initiating timely referrals to physician advisors when potential utilization issues are identified, ensuring expert clinical oversight.
• • You will collaborate closely with the financial clearance center, patient access teams, financial counselors, and the business office to address and resolve billing issues related to third-party payers, ensuring seamless financial operations.
• • Your expertise will be crucial in communicating medical necessity review outcomes to in-house care management staff and other relevant parties, fostering a coordinated approach to patient care.
• • You will actively engage with in-house staff and physicians to clarify information, obtain necessary documentation, identify opportunities for improvement, and educate on the appropriate level of care.
• • In the realm of denial management, you will coordinate the Peer-to-Peer (P2P) process with physicians or physician advisors, the Financial Clearance Center (FCC), and the Revenue Cycle team when necessary, maintaining meticulous documentation relevant to the appeal process.
• • Your efforts will contribute to minimizing denial rates by maintaining appropriate information on file and assisting in recording denial updates, including overturned days and monitoring/reporting denial trends.
• • You will also monitor for patient readmissions, contributing to quality improvement initiatives.
• • Demonstrating active collaboration with other members of the healthcare team is essential to achieve outcomes management goals, including adherence to CMS indicators.
• • Accurate data recording for statistical entry and timely submission of information are paramount to maintaining operational efficiency and reporting accuracy.
• • You will be responsible for managing assigned ConnectCare and ADT work queues within the revenue cycle workflow.
• • Your documentation will be comprehensive, reflecting all work and communication with the FCC, payors, physicians, physician advisors, and in-house care management.
• • You will facilitate second-level physician reviews as required, ensuring that all responses and actions are accurately reflected in patient records.
• • Prioritizing patient reviews based on situational analysis, functional assessment, medical record review, and application of clinical review criteria will be a daily responsibility.
• • Maintaining strong rapport and open communication with in-house care managers is vital for effective patient care facilitation.
• • You will demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served, understanding the principles of growth and development across the lifespan.
• • Your ability to assess patient status, interpret data, and identify patient requirements relative to their age and specific needs will be critical.
• • Directing physician and patient communication regarding non-coverage of benefits requires tact and clarity.
• • Maintaining positive, open communication with physicians, nurses, multidisciplinary team members, and administration is key to fostering a collaborative environment.
• • You will educate hospital and medical staff regarding the utilization review program, promoting best practices.
• • Maintaining a calm, rational, and professional demeanor, even in conflict or crisis situations, is essential for effective team interaction.
• • Timely utilization of voicemail, Skype, and email, along with prompt responses to communication from the FCC via approved guidelines, is expected.
• • You will be available for designated meetings or training sessions, whether onsite or online, unless prior arrangements are made.
• • Working collaboratively with peers to achieve departmental goals, demonstrating respect, clarity, and sensitivity to workload, is a core team function.
• • You will actively participate in departmental process improvement teams, contributing to planning, implementation, and evaluation activities.
• • Providing back-up support to other departmental staff as needed ensures operational continuity.
• • Compliance with FCC and department policies and procedures, including confidentiality and patient rights, is mandatory.
• • Maintaining clinical competency and current knowledge of regulatory and payer requirements, such as medical necessity criteria, MS-DRGs, and POA, is crucial for job performance.
• • Active participation in departmental meetings and activities, as well as assigned committees and task forces, is expected.
• • This is a remote role requiring high-speed internet access and the ability to work independently while maintaining strong communication and problem-solving skills.
• • Your commitment to exceptional customer service and effective verbal and written communication will be instrumental in achieving desired patient, quality, and financial outcomes.