Utilization Review Physician Full Time
3 weeks ago
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.
Our Network
Hackensack Meridian Health (HMH) is a Mandatory Influenza Vaccination Facility
As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.
-
Care Coordinator, Utilization Management
2 months ago
Hackensack, United States Hackensack Meridian Health Full timeOverview: Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. Its also about how we support one...
-
Care Coordinator, Utilization Management
2 months ago
Hackensack, United States Hackensack Meridian Health Full timeOverview: Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. Its also about how we support one...
-
Care Coordinator, Utilization Management
1 month ago
Hackensack, United States Hackensack Meridian Health Full timeOur team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another...
-
Clinical Supervisor, LPN
4 weeks ago
Hackensack, United States HMH PHYSICIAN SERVICES, INC. Full timeOur team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another...
-
Collaborating Physician/Physician
3 months ago
Hackensack, United States Your Wellness Care Part time $750 - $1,250Collaborating PhysicianPrimary Care 341-345 Essex StreetHackensack, NJ 07601Resume InsightsEducation & Certificates:Doctoral degree.Medical License.Job details:Salary.Pay: $750-1250/month for 2hrs/week.Job Type.Part-time available at 100/hr for 20 hours as well. Contract.Qualifications:Doctorate. (Required)Medical License- Unrestricted. (Required)US work...
-
Neonatal ICU Physician Assistant
1 month ago
Hackensack, New Jersey, United States HMHMG SPECIALTY CARE 570 Full timeJob Title: Advanced Practice Nurse or Physician AssistantThis is a full-time position in the Level III Neonatology Department at Hackensack University Medical Center.The successful candidate will perform the role of an Advanced Practice Nurse or Physician Assistant, utilizing the patient-centered coordinated care model, with competencies in leadership,...
-
Hackensack, United States Hackensack Meridian Health Full timeOverview The Interventional Pain Management Nurse Practitiner or Physician Assistant for Hackensack UMC's Pain and Palliative Care performs the role utilizing the patient-centered coordinated care model demonstrated through the following competencies: leadership, direct clinical practice, consultation/collaboration, coaching/guiding, research, and ethical...
-
Supervisor, Radiology
5 months ago
Hackensack, United States Hackensack Meridian Health Full timeOverview Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support...
-
Audiologist I, Full-Time
3 months ago
Hackensack, United States Hackensack Meridian Health Full timeOverview: Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. Its also about how we support one...
-
Audiologist I, Full-Time
2 months ago
Hackensack, United States Hackensack Meridian Health Full timeOverview Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives - and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It's also about how we support one...
-
Critical Care Clinical Pharmacist
4 months ago
Hackensack, United States Hackensack Meridian Health Full timeOverview: Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. Its also about how we support one...
-
Care Coordinator, Care Management
5 months ago
Hackensack, United States Hackensack Meridian Health Full timeOverview: Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. Its also about how we support one...
-
Nurse Practitioner Physician Assistant NICU
2 months ago
Hackensack, United States HMHMG SPECIALTY CARE 570 Full timeThis fulltime APP position is for the Level III Neonatalogy Department at Hackensack University Medical Center The Advanced Practice Nurse or Physician Assistant performs the role utilizing the patient-centered coordinated care model demonstrated through the following competencies: leadership, direct clinical practice, consultation/collaboration,...
-
Care Coordinator, Care Management
4 weeks ago
Hackensack, United States Hackensack Meridian Health Full timeOverview Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives - and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It's also about how we support one...
-
Care Coordinator, Care Management
5 months ago
Hackensack, United States Hackensack Meridian Health Full timeOverview Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives - and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It's also about how we support one...
-
Physical Therapist- Full-Time
4 days ago
Hackensack, United States JAG Physical Therapy Full timePhysical TherapistThe Physical Therapist is forward-thinking who excels at assessing patients' strengths and weaknesses and devising creative and effective treatment plans. Therapists must practice discretion & maintain patient confidentiality. Must operate a high-energy, positive-thinking environment and offer patients positive encouragement to achieve...
-
Physical Therapist- Full-Time
3 days ago
Hackensack, United States JAG Physical Therapy Full timePhysical TherapistThe Physical Therapist is forward-thinking who excels at assessing patients' strengths and weaknesses and devising creative and effective treatment plans. Therapists must practice discretion & maintain patient confidentiality. Must operate a high-energy, positive-thinking environment and offer patients positive encouragement to achieve...
-
Certified Respiratory Therapist
1 month ago
Hackensack, New Jersey, United States Hackensack Meridian Health Full timeJob SummaryWe are seeking a skilled Certified Respiratory Therapist to join our team at Hackensack Meridian Health. As a key member of our Respiratory Care department, you will be responsible for providing high-quality patient care and administering respiratory therapy treatments.ResponsibilitiesAssist in the diagnosis, treatment, and management of patients...
-
Hackensack, New Jersey, United States Hackensack Meridian Health Full timeJob Title: Nurse Practitioner Physician Assistant Vascular SurgeryJoin Hackensack Meridian Health as a Nurse Practitioner or Physician Assistant for Vascular Surgery and contribute to delivering exceptional patient care.Key Responsibilities:Lead decisions affecting APRN practice and advance nursing practice within the institution.Seek opportunities to...
-
Licensed Physical Therapist
4 weeks ago
Hackensack, United States Tender Touch Rehab Services, LLC Full timeOverview: Must be a licensed and or a registered therapist to be considered. EXCLUSIVE NEW JOB OPPORTUNITY Highly competitive rates and benefits package! Do you know a therapist who's a perfect fit for our team? EARN UP TO $1,000 by referring a clinician to the Enhance family of brands! Make a difference and get rewarded for it! About Us: Tender Touch Rehab...
