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Sr Utilization Review Spec- Physician FT HUMC - Hackensack, United States - Hackensack Meridian Health
Description
Overview
The Senior Utilization Review Physician 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 HackensackUMC.
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
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
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
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
a. Tools to assist with care coordination decision making
b. Liaison with 3rd party payers as needed
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
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)
b. Collaborates with the CDI team as needed
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.
Job ID _ _
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 _No Holidays Required_
