Physician Utilization Review Specialist Per Diem

Hackensack University Medical Center•Hackensack, NJ

43d•$103

About The Position

The Senior Utilization Review Specialist collaborates with the healthcare team in the management and resolution of activities that assure the integrity of clinical records for the patient population and Hackensack UMC. These include but are not limited to utilization review, hospital reimbursement, clinical compliance, case management, and transitions of care, as outlined in the responsibilities below. Weekend and holiday coverage required as needed based on dept needs.

Requirements

Medical degree from a recognized Medical School.
Completion of a residency program from an accredited medical institution.
Minimum of 3 years medical practice experience.
Ability to effectively communicate with professional peers, department members and all levels of administration.
Medical Doctor License.

Nice To Haves

Maintains at least one Medical Board Certification.
At least two years experience in Utilization Review processes including knowledge of regulatory requirements relative to performing status determinations and Peer to Peer denial interactions with medical directors of third-party payers.

Responsibilities

Regulatory compliance
Provides direction and support regarding CMS & NJDOH regulations governing Utilization Management & Clinical documentation.
Oversight for accurate patient status determinations - OBS vs. Inpatient
Liaison to the Medical Staff supporting Utilization Management Committee processes
Hospital Based Appeals Management
Provides guidance and interpretation on issues of medical appropriateness and level of care needs
Liaison between medical staff and other clinical staff by being:
Excellent communicator
Broad spectrum clinical knowledge base
Expert resource related to admission criteria, observation status criteria and documentation requirements
Education/Advisory
Physician Educator
Provide formal educational lectures and engage in frequent informal meetings
Retrospective Medical Record Documentation Review
Clarifying ambiguous or conflicting documentation
Target DRGs Reviews
Use of case manager as a resource
Uses guidelines to evaluate patient status based on length of stay, level of care requirements and Medicare regulations, and Major Complications or Comorbidities (MCC) / Complications or Comorbidities (CC) categories documentation and identification
Tools to assist with care coordination decision making
Liaison with 3rd party payers as needed
Leadership, Staff Management and Organizational Strategy
Development & implementation of Utilization Management strategies to assure appropriate health care delivery in appropriate setting
Provides guidance & support for executing targeted Utilization Management Strategies and relevant Improvement
Works with Clinical Delivery and Operations leadership to support, and provide assistance and support in overall medical management effectiveness, benchmarked utilization and cost management (UM) goals and clinical improvement objectives
Interfaces with Clinical Team in regards to Utilization Management and evidence based medicine
Provides professional support to the functions within the Utilization Management Department
Provides periodic written and verbal reports and updates regarding Utilization Management as required
Promotes and supports a working environment consistent with the values-based culture of Hackensack Meridian Health
Supports the Revenue Cycle Clinical Team in planning, coordinating and executing protocols, policies and strategies within the department
Partners with Senior Leadership and other stakeholders to achieve strategic objectives through successful implementation/completion of strategic initiatives
Develop strategies across all functional departments to reduce clinical denials by:
Peer-to Peer (P2P) Concurrent appeals
Written Concurrent appeals
Recovery Audit Contractors & levels of appeal
Root cause analysis & trends
Participation in Managed Care Contracting & distribution of contract terms where appropriate
Utilization Review Process
Subject Matter Expert in the use & application of Utilization Management Criteria ( i.e. MCG, Xsolis)
Supports & Participates in pre-admission review, utilization management, and concurrent and retrospective review process.
Review and facilitate appropriate Level of Care Determinations (Inpatient, Observation, Outpatient/Ambulatory)
Conducts and/or supports improvement and outcomes studies related to Utilization Management (Self-Audits & other auditing activities)
Electronic Health Record (EHR)/Other Technology
Partners with Operations and Senior Leadership to assess and implement technology
Collaborates with the CDI team as needed
Other duties as assigned