RN, Senior Utilization Review Quality

About this role

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

• Paid Certifications

• Tuition Reimbursement

• Comprehensive Benefits

• Career Advancement

• This position pays between $47.03 - $63.48/hr based on experience

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Please note that the VUR department operates 7 days per week from 8:00 a.m. to 10:00 p.m., and candidates must be willing and able to work within these scheduled hours, including weekends as needed.

By embodying our core purpose of customer obsession, new ideas, and driving innovation, and delivering excellence, you will help ensure that every touchpoint is meaningful and contributes to our mission of redefining the possible in healthcare.

The RN, Senior Utilization Review Quality will play an essential role in reviewing and ensuring the quality of the VUR teams’ work efforts in partnership with the Leadership Team. The primary responsibility of this role is to perform independent account reviews on cases that have been worked by our entry level and senior level Revenue Cycle team members with the purpose of identifying opportunity and making recommendations for improvement to the operational and executive leaders.
This role will assist with continued training, education and ongoing action plans to ensure quality is consistently met for existing teams in partnership with the Leadership Team. In addition, this role will be responsible for onboarding support including user provisioning as required in partnership with Leadership Team.

Essential Job Functions:

• Mentors other UR Quality Specialist and UR team members to help develop and improve their skills in the quality review process.

• Assesses the Quality Assurance process and actively looks for opportunities to increase efficiency and proactively brings to Leadership attention.

• Evaluate operational and management VUR policies/procedures for entry level and senior level Team to provide input into the annual review workplan.

• Performs Quality reviews across multiple clients, working in a variety of host systems. Conduct root cause analysis on audit findings, quality assurance audits and utilization management denials.

• Coordinate with service line leaders and partner with upper level Leadership, to identify areas of risk and assist leadership in developing a quarterly/ annual review plan.

• Develop a thorough understanding of business processes in scope for assigned reviews and document the processes. Well versed in VUR processes, protocols, and best practices.

• Perform account level review for entry and senior level individuals to ensure consistency with best practices including but not limited to Quality Audit to confirm implementation and effectiveness of policies/procedures.

• Performs reviews to measure compliance with policies, procedures, workflow, and other applicable requirements.

• Identify and document operational, compliance, and quality risks and make recommendations to mitigate risks.

• Prepare and present quality reports of review findings and recommendations to direct leadership for review and approval.

• Participate in pre- & post-review meetings, providing support and recommendations for issues presented.

• Ensure past review recommendations are implemented in current review process.

• Maintain current knowledge of laws/regulations regarding medical necessity, clinical documentation, compliance standards, reviewing, other general clinical and/or business matters related to the service line they are working.

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 required

• 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:

• Excellent interpersonal, communication and negotiatioies Required:n 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…