Senior Physician Specialist in Utilization Review
2 weeks ago
Overview
The Senior Physician Specialist in Utilization Review collaborates with the healthcare team to oversee and resolve activities that ensure the accuracy of clinical documentation for the patient population and Hackensack Meridian Health. Responsibilities encompass utilization review, hospital reimbursement, clinical compliance, case management, and transitions of care, as detailed below.
Key Responsibilities
1. Regulatory Compliance
a. Offer guidance and support concerning CMS & NJDOH regulations that govern Utilization Management & Clinical documentation.
b. Ensure accurate patient status determinations - OBS vs. Inpatient.
c. Act as a liaison to the Medical Staff to support Utilization Management Committee processes.
d. Manage Hospital Based Appeals.
e. Provide insights and interpretations on medical appropriateness and level of care needs.
2. Liaison Role
a. Serve as an effective communicator.
b. Maintain a broad clinical knowledge base.
c. Act as an expert resource regarding admission criteria, observation status criteria, and documentation requirements.
3. Education and Advisory
a. Function as a Physician Educator.
I. Deliver formal educational sessions and engage in frequent informal discussions.
ii. Conduct retrospective medical record documentation reviews.
iii. Clarify ambiguous or conflicting documentation.
iv. Review Target DRGs.
v. Utilize case managers as a resource.
4. Evaluation of Patient Status
a. Apply guidelines to assess patient status based on length of stay, level of care requirements, Medicare regulations, and Major Complications or Comorbidities (MCC) / Complications or Comorbidities.
5. Documentation and Identification
a. Utilize tools to aid in care coordination decision-making.
b. Liaise with third-party payers as necessary.
6. Leadership and Organizational Strategy
a. Develop and implement Utilization Management strategies to ensure appropriate healthcare delivery in suitable settings.
b. Provide guidance and support for executing targeted Utilization Management strategies and relevant improvements.
c. Collaborate with Clinical Delivery and Operations leadership to enhance medical management effectiveness, benchmarked utilization, and cost management goals.
d. Interface with the Clinical Team regarding Utilization Management and evidence-based medicine.
e. Offer professional support to functions within the Utilization Management Department.
f. Provide periodic written and verbal reports and updates on Utilization Management as required.
g. Foster a working environment aligned with the values-based culture of Hackensack Meridian Health.
h. Support the Revenue Cycle Clinical Team in planning, coordinating, and executing protocols, policies, and strategies within the department.
i. Partner with Senior Leadership and other stakeholders to achieve strategic objectives through successful implementation of initiatives.
j. Develop strategies across all functional departments to minimize clinical denials through various appeals processes and analyses.
7. Utilization Review Process
a. Serve as a Subject Matter Expert in the application of Utilization Management Criteria (e.g., MCG).
b. Support and participate in pre-admission review, utilization management, and concurrent and retrospective review processes.
c. Review and facilitate appropriate Level of Care Determinations (Inpatient, Observation, Outpatient/Ambulatory).
d. Conduct and support improvement and outcomes studies related to Utilization Management (Self-Audits & other auditing activities).
8. Technology and Electronic Health Records (EHR)
a. Collaborate with Operations and Senior Leadership to assess and implement relevant technology.
b. Work in conjunction with the CDI team as needed.
Qualifications
Education, Knowledge, Skills, and Abilities Required:
1. Medical degree from an accredited medical school.
2. Completion of a residency program from an accredited medical institution.
3. A minimum of 3 years of medical practice experience.
4. Strong communication skills with professional peers, department members, and all levels of administration.
Licenses and Certifications Required:
1. Medical Doctor License.
Licenses and Certifications Preferred:
1. Maintenance of at least one Medical Board Certification.
Our Network
Hackensack Meridian Health (HMH) is a Mandatory Influenza Vaccination Facility.
We aim to assist you in your job search by connecting your resume with other areas of our Hackensack Meridian Health network that may have current openings fitting your skills and experience.
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Hackensack, New Jersey, United States Hackensack Meridian Health Full timeOverview The Senior Physician Specialist in Utilization Review plays a pivotal role in collaborating with the healthcare team to ensure the accuracy and integrity of clinical documentation for patients within the Hackensack Meridian Health network. This position encompasses a variety of responsibilities including utilization review, hospital reimbursement,...
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Hackensack, New Jersey, United States Hackensack Meridian Health Full timePosition Overview The Senior Physician Specialist in Utilization Review plays a crucial role in collaborating with the healthcare team to ensure the accuracy and integrity of clinical documentation for the patient population at Hackensack Meridian Health. This position encompasses various responsibilities, including utilization review, hospital...
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