At Bon Secours Mercy Health, we are dedicated to continually improving health care quality, safety and cost effectiveness. Our hospitals, care sites and clinicians are recognized for clinical and operational excellence. **This is a Collective Bargaining Unit Position.** **Job Summary:** 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. **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. _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 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 (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 perform other job-related duties as required by their supervisor, subject to reasonable accommodation. **Employment Qualifications:** _Required Minimum Educations:_ 4 year/Bachelor's Degree; Specialty/Major: Nursing _Licensure/Certification_ _Required:_ Current unrestricted LPN or RN license to practice nursing in Ohio, or a compact license. _Minimum Years and Type 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. _Other Knowledge, Skills, and Abilities Required:_ Excellent interpersonal, communication and negotiation skills in interactions with physicians, payors, and health care team colleagues. Remain focused on customer service at all times. Communicate ideas and thoughts effectively verbally and in written form. Able to participate collaboratively with all members of care team. 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 organize information quickly and effectively; prioritize and complete multiple tasks effectively. Ability to work independently. _Other Knowledge, Skills, and Abilities Preferred:_ Strong analytical and computer skills. Ability to think critically and formulate ideas easily. Basic computer skills with competency in Microsoft Office products to include Excel, Word, Outlook, and PowerPoint. Adapt to an ever-changing environment and remain flexible in various situations and problems. Many of our opportunities reward* your hard work with: Comprehensive, affordable medical, dental and vision plans Prescription drug coverage Flexible spending accounts Life insurance w/AD&D Employer contributions to retirement savings plan when eligible Paid time off Educational Assistance And much more *Benefits offerings vary according to employment status All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com . If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com