Virtual Utilization Review Supervisor

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 $84,000 – $126,000 based on experience

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 Virtual Utilization Review Supervisor is a key contributor to the overall financial, quality, and clinical performance of the organization. The VUR Supervisor supports an outcomes-oriented, patient care delivery system, which places the patient at the center of all activities. The Supervisor Virtual Utilization Review facilitates the improvement of overall quality and completeness of medical record documentation. The VUR Supervisor 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.
Job Responsibilities will include, but are not limited to:

• RESOURCE 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 hospital liaison. 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 daily. 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 within one business day of admission. Communicates all medical necessity review outcomes to hospital liaison. Collaborates with the liaison 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 appeal process with the liaison, 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 and report possibilities for readmission and current readmissions to the liaison.

• 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 work queues assigned to case management 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 Financial Clearance Center and hospital-based liaison. Second-level physician reviews will be sent as required and responses/actions reflected in documentation.

• FACILITATION OF PATIENT CARE: Prioritizes patient care needs based on situational analysis, functional assessment, medical record review, and application of clinical review criteria. Collaborates with the liaison in developing and expanding the plan of care to encompass multidisciplinary patient care needs. Maintains rapport and communication with the liaison to monitor and evaluate the plan of care. Identifies variances in plan and adjust as required to ensure continuity of care. Collaborates with the liaison to direct care towards predictable outcomes. Demonstrates the 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…