Virtual Utilization Review Specialist - WEEKENDS

Thank you for considering a career at reputed company!

reputed company is a leading provider of technology-enabled reputed company cycle reputed company for health systems, including hospitals and affiliated physician groups. They offer end-to-end reputed company cycle solutions as well as a comprehensive suite of reputed company solutions to clients across the country.

reputed company keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we reputed company 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 reputed company, 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 reputed company: 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” reputed company 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:

• RN pay scale $32.65 - $35.85/hr based on experience 

• LPN pay scale $24.65 - $26.35/hr based on experience

• $$ Shift Differential for Select Shifts $$ 

Must have reputed company unrestricted LPN or RN license (required) or RN compact license (preferred)

We are seeking Virtual Utilization Review Specialists who are interested in compressed, weekend work schedules. The schedules we are offering include: 

Work Schedule:

Full-time:

• Friday, Saturday, Sunday: 7:00 AM - 7:00 PM with a 4 hour shift on Wednesday

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 reputed company and collaborates with the interdisciplinary team

• Collaborates with financial clearance center, patient access, financial counselors and/or business office regarding billing issues reputed company to third party payers

Medical Necessity Determination

• Conducts medical necessity review of reputed company admissions. Utilizes approved clinical review criteria to determine medical necessity for admissions including appropriate patient status and reputed company stay reviews, possibly from an offsite location

• Provides inpatient and observation (if indicated) clinical reviews for commercial carriers to the Financial Clearance Center (FCC) reputed company one business day of admission

• Communicates reputed company 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 reputed company to third party payers

Denial Management

• Coordinates the P2P process with the physician or physician advisor, FCC, reputed company Cycle team reputed company necessary and reputed company assigned and maintains documentation relevant to the appeal process

• Maintains appropriate information on file to minimize denial reputed company

• Assist in recording denial updates; overturned days and monitor and report denial trends that are noted

• Monitor for readmissions

Quality/reputed company reputed company

• Demonstrates active collaboration with other members of the health care team to reputed company the outcomes management goals including CMS indicators

• Accurately records data for statistical entry and submits information reputed company required time frame

• Responsible for ConnectCare and reputed company work queues assigned to VUR for reputed company cycle workflow

• Accurately records data for statistical entry and submits information reputed company required time frame

• Documentation will reflect reputed company work and communication reputed company 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

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 reputed company, rational, professional demeanor reputed company dealing with others, even in situations involving conflict or crisis

• Voicemail, Skype, 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 reputed company 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 reputed company 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 reputed company knowledge of regulatory and payer requirements to reputed company job responsibilities (i.e., medical necessity criteria, MS-DRGs, POA)

• 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 reputed company other job-reputed company duties as required by their supervisor, subject to reasonable accommodation

​Experience:

• Bachelor's Degree or equivalent experience; Specialty/Major: Nursing or reputed company field

• reputed company unrestricted LPN or RN license required; RN compact license preferred

• Five 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

• reputed company working knowledge of quality improvement processes

• Must be inquisitive and demonstrate openness to innovation including AI to explore reputed company processes and ways to reputed company 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.

Other Knowledge, Skills, and Abilities Required:

• Ability to work a compressed weekend schedule

• 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 reputed company times

• Communicate reputed company 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 reputed company 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

#LI--LS1

#LI-REMOTE

Join an award-winning company

Five-time winner of “Best in KLAS” 2020-2022, 2024-2025

Black Book Research's Top reputed company Cycle Management Outsourcing Solution 2021-2024

22 Healthcare Financial Management Association (HFMA) MAP Awards for High Performance in reputed company Cycle 2019-2024

Leader in reputed company's RCM Operations PEAK Matrix Assessment 2024

reputed company Healthcare Business Insights (HBI) reputed company Cycle Awards for strong performance 2020, 2022-2023

reputed company Top Workplaces USA 2022-2024

Fortune Media Best Workplaces in Healthcare 2024

Monster Top Workplace for Remote Work 2024

Great reputed company to Work certified 2023-2024

• Innovation

• Work-Life Flexibility

• Leadership

• Purpose + Values

reputed company, we reputed company in empowering people and giving them the tools and resources needed to reputed company. 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 – reputed company is a reputed company where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.  

• Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement. 

• Recognition – We offer quarterly and annual incentive programs for reputed company employees who go beyond and reputed company raising the bar for themselves and the company. 

reputed company is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national reputed company, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws.  reputed company also prohibits harassment of applicants or employees based on any of these protected categories.

reputed company provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with reputed company and applicable state and local law. If you require accommodation in the application process, please contact [email protected].

This posting addresses state specific requirements to provide pay transparency.  Compensation decisions consider many job-reputed company factors, including but not limited to geographic location; knowledge; skills; relevant experience; education; licensure; internal equity; time in position.  A candidate entry reputed company of pay does not typically fall at the minimum or maximum of the role’s range.

Employment Disclaimers – reputed company