Utilization Review Specialist at Ensemble Health Partners

Ensemble Health Partners

Utilization Review Specialist



Remote – Nationwide



Thank you for considering a career at Ensemble Health Partners!

Summary of Primary Function

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

SCHEDULE: 3- 12s (36hrs)

Essential Job Functions

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 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 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 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 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.


  • 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, lync and email will be utilized and answered in 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.

Required Minimum Education: 4-year degree

Preferred Education: RN

Minimum Years of Experience:

  • Five years nursing experience in an acute care environment required. Utilization review/discharge planning experience preferred.
  • Recent and working knowledge of medical necessity review criteria experience preferred.
  • Current working knowledge of quality improvement process preferred.
  • Ability to receive high-speed internet at home

Scheduled Weekly Hours: 40

Work Shift:

Weekends (United States of America)

We’ll also reward your hard work with:

  • Great health, dental and vision plans
  • Prescription drug coverage
  • Flexible spending accounts
  • Life insurance w/AD&D
  • Paid time off
  • Tuition reimbursement
  • And a lot more

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