Ensemble Health Partners
Utilization Review RN
Swindon
$63.1k – $94.7k/yr
Posted about 20 hours ago
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Thank you for considering a career at Ensemble!
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. 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 Incentives
- Shift Differentials
- Paid Certifications
- Tuition Reimbursement
- Comprehensive Benefits
- Career Advancement
Salary Range: $63,100 - $94,650 annually, dependent upon experience, education, certifications, and overall qualifications.
Requirements:
- Must have current compact RN license, or be willing to obtain
- NICU and/or Pediatric nursing experience is strongly preferred
Schedule Information:
- Coverage: Seven days a week, operating between 8:00 a.m. and 10:00 p.m.
- Schedule: 4x10 schedule (four 10-hour shifts each week)
- Shifts:
- 10:00 a.m. - 8:00 p.m.
- 12:00 p.m. - 10:00 p.m. (eligible for a 10% shift differential)
- Weekend Rotation: Team members are expected to work every other weekend.
Benefits & Additional Compensation
- 10% weekend differential for hours worked on weekends.
- 10% shift differential for hours worked during the 12:00 p.m. - 10:00 p.m. shift.
- Differentials compound for eligible hours worked.
Essential Job Functions
-
Resource Utilization:
- Utilizes proactive triggers 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 financial clearance center, patient access, financial counselors, and/or business office regarding billing issues
-
Medical Necessity Determination:
- Conducts medical necessity review of all admissions
- 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
- Collaborates with the in-house staff and/or physician to clarify information, obtain needed documentation, present opportunities, and educate regarding appropriate level of care
-
Denial Management:
- Coordinates the P2P process with the physician or physician advisor, FCC, Revenue Cycle team when necessary
- 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
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-
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
- 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 required and responses/actions 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 the patients served on his or her assignment
- Demonstrates 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 identify each patient's requirements relative to his or her age, specific needs, and to provide the care needed as described in departmental policies and procedures
-
Communication:
- Directs physician and patient communication regarding non-coverage of benefits
- Maintains positive, open communication with the 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 situations involving conflict or crisis
- Voicemail, Skype, and email will be utilized and answered in a timely fashion. Hospital provided communication devices will be used during work hours.
- Staff is expected to respond and/or acknowledge communication from the FCC via approved communication guidelines and standardized service-line agreements
- Staff must be available as designated for meetings or training, onsite or online, unless prior arrangements are made
-
Team Affirmation:
- Works collaboratively with peers to achieve departmental goals in daily work as evidenced by appropriate and timely communication which is respectful and clear. Sensitive to workload of peers and shares responsibilities, fills in, and offers to help.
- Actively participates in departmental process improvement team; planning, implementation, and evaluation of activities.
- Provides back-up support to other departmental staff as needed.
Other Job Functions
- Complies with FCC and department policies and procedure, including confidentiality and patient’s rights.
- Maintains clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities.
- 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.
- Associates may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation.
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Experience:
- Bachelor's Degree or equivalent experience; Specialty/Major: Nursing or related field
- Current unrestricted RN license required; RN compact license preferred
- 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
Other Knowledge, Skills, and Abilities Required:
- This is a remote role which requires access to high-speed internet
- Excellent interpersonal, communication, and negotiation skills in interactions with physicians, payors, and health care team colleagues
- Commitment to exceptional customer service at all times
- Communicate ideas and thoughts effectively verbally and in writing
- Strong clinical assessment, organization, and problem-solving skills
- Ability to assess and identify appropriate resources, internal and community, on assigned caseload, and to work collaboratively with health care team, providers, and payors to achieve the desired patient, quality, and financial outcomes
- Ability to prioritize, organize information, and complete multiple tasks effectively in a fast-paced environment
- Resourceful and able to work independently
- Must be inquisitive and demonstrate openness to innovation including AI to explore better processes and ways to alleviate friction and improve patient and client experiences
- 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
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Join an award-winning company
- 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
Innovation
Work-Life Flexibility
Leadership
Purpose + Values
Bottom line, we believe in empowering people and giving them the tools and resources needed to thrive. A few of those include:
- Associate Benefits: We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.
- Our Culture: Ensemble is a
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