Physician Utilization Review Specialist Per Diem HUMC

3 days ago


Hackensack, New Jersey, United States Hackensack Meridian Health Full time
Job Summary

We are seeking a highly skilled Physician Utilization Review Specialist to join our team at Hackensack Meridian Health. As a key member of our healthcare team, you will play a critical role in ensuring the integrity of clinical records and promoting high-quality patient care.

Key Responsibilities
  • Regulatory Compliance
    • Provide 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
    • 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.
  • Utilization Review Process
    • Subject Matter Expert in the use & application of Utilization Management Criteria (i.e. MCG).
    • 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.
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.
Licenses and Certifications
  • Medical Doctor License.
  • Maintains at least one Medical Board Certification.


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