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Hackensack Meridian Health

Utilization Review Physician Full Time

Hackensack Meridian Health, Hackensack, New Jersey, us, 07601


Overview

The Utilization Review Physician 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.

Responsibilities

Essential Job Functions:

1. Regulatory compliance

a. Provides direction and support regarding CMS & NJDOH regulations governing Utilization

Management & Clinical documentation.

b. Oversight for accurate patient status determinations - OBS vs. Inpatient

c. Liaison to the Medical Staff supporting Utilization Management Committee processes

d. Hospital Based Appeals Management

e. Provides guidance and interpretation on issues of medical appropriateness and level of care

needs

2. Liaison between medical staff and other clinical staff by being:

a. Excellent communicator

b. Broad spectrum clinical knowledge base

c. Expert resource related to admission criteria, observation status criteria and documentation

requirements

3. Education/Advisory

a. Physician Educator

I. Provide formal educational lectures and engage in frequent informal meetings

ii. Retrospective Medical Record Documentation Review

iii. Clarifying ambiguous or conflicting documentation

iv. Target DRGs Reviews

v. Use of case manager as a resource

4. 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

5. (CC) categories documentation and identification

a. Tools to assist with care coordination decision making

b. Liaison with 3rd party payers as needed

6. Leadership, Staff Management and Organizational Strategy

a. Development & implementation of Utilization Management strategies to assure appropriate

health

care delivery in appropriate setting

b. Provides guidance & support for executing targeted Utilization Management Strategies and

relevant

Improvement

c. 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

d. Interfaces with Clinical Team in regards to Utilization Management and evidence based

medicine

e. Provides professional support to the functions within the Utilization Management Department

f. Provides periodic written and verbal reports and updates regarding Utilization Management as

required

g. Promotes and supports a working environment consistent with the values-based culture of

Hackensack Meridian Health

h. Supports the Revenue Cycle Clinical Team in planning, coordinating and executing protocols,

policies and strategies within the department

I. Partners with Senior Leadership and other stakeholders to achieve strategic objectives

through

successful implementation/completion of strategic initiatives

j. Develop strategies across all functional departments to reduce clinical denials by:

I. Peer-to Peer (P2P) Concurrent appeals

ii. Written Concurrent appeals

iii. Recovery Audit Contractors & levels of appeal

iv. Root cause analysis & trends

v. Participation in Managed Care Contracting & distribution of contract terms where appropriate

7. Utilization Review Process

a. Subject Matter Expert in the use & application of Utilization Management Criteria ( i.e. MCG,

Xsolis)

b. Supports & Participates in pre-admission review, utilization management, and concurrent and

retrospective review process.

c. Review and facilitate appropriate Level of Care Determinations (Inpatient, Observation,

Outpatient/Ambulatory)

d. Conducts and/or supports improvement and outcomes studies related to Utilization

Management

(Self-Audits & other auditing activities)

8. Electronic Health Record (EHR)/Other Technology

a. Partners with Operations and Senior Leadership to assess and implement technology

b. Collaborates with the CDI team as needed

9. Other duties as assigned

Qualifications

Education, Knowledge, Skills and Abilities Required:

1. Medical degree from a recognized Medical School.

2. Completion of a residency program from an accredited medical institution.

3. Minimum of 3 years medical practice experience.

4. Ability to effectively communicate with professional peers, department members and all levels

of administration.

Education, Knowledge, Skills and Abilities Preferred:

Licenses and Certifications Required:

1. Medical Doctor License.

Licenses and Certifications Preferred:

1. Maintains at least one Medical Board Certification.

2. 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.

Job ID 2024-155583

Department Utilization Review

Site Hackensack University Med Cntr

Job Location US-NJ-Hackensack

Position Type Full Time with Benefits

Standard Hours Per Week 40

Shift Day

Shift Hours varies

Weekend Work Weekends as Needed

On Call Work No On-Call Required

Holiday Work As Needed