Senior Physician Specialist in Utilization Review
2 weeks ago
Overview
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, clinical compliance, case management, and care transitions, as detailed below.
Key Responsibilities
1. Regulatory Compliance
a. Offer guidance and support concerning CMS and NJDOH regulations related to Utilization Management and clinical documentation.
b. Ensure accurate patient status determinations between Observation and Inpatient care.
c. Act as a liaison to the Medical Staff, facilitating Utilization Management Committee processes.
d. Manage hospital-based appeals effectively.
e. Provide expert guidance on medical appropriateness and level of care requirements.
2. Interdepartmental Liaison
a. Serve as an excellent communicator.
b. Maintain a broad clinical knowledge base.
c. Act as an expert resource for admission criteria, observation status criteria, and documentation requirements.
3. Education and Advisory Role
a. Function as a Physician Educator.
i. Deliver formal educational sessions and engage in regular informal discussions.
ii. Conduct retrospective reviews of medical record documentation.
iii. Clarify ambiguous or conflicting documentation.
iv. Review targeted Diagnosis-Related Groups (DRGs).
v. Utilize case managers as a resource.
4. Utilization Review Process
a. Act as a Subject Matter Expert in the application of Utilization Management Criteria (e.g., MCG).
b. Support and participate in pre-admission reviews, utilization management, and concurrent and retrospective review processes.
c. Facilitate appropriate Level of Care determinations (Inpatient, Observation, Outpatient/Ambulatory).
d. Conduct and support improvement and outcomes studies related to Utilization Management.
5. Leadership and Strategy Development
a. Develop and implement strategies for Utilization Management to ensure appropriate healthcare delivery.
b. Provide guidance and support for executing targeted Utilization Management strategies and improvements.
c. Collaborate with Clinical Delivery and Operations leadership to enhance medical management effectiveness and achieve utilization and cost management goals.
d. Interface with the Clinical Team regarding Utilization Management and evidence-based practices.
e. Offer professional support to functions within the Utilization Management Department.
f. Provide periodic reports and updates regarding 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 and executing departmental protocols and strategies.
i. Partner with Senior Leadership and stakeholders to achieve strategic objectives through successful implementation of initiatives.
j. Develop strategies across departments to minimize clinical denials through various appeal processes.
6. Electronic Health Record (EHR) and Technology Integration
a. Collaborate with Operations and Senior Leadership to assess and implement relevant technology.
b. Work with the Clinical Documentation Improvement (CDI) team as necessary.
Qualifications
Education, Knowledge, Skills, and Abilities Required:
1. Medical degree from an accredited medical school.
2. Completion of a residency program from an accredited institution.
3. A minimum of three years of medical practice experience.
4. Strong communication skills with peers, department members, and administration.
Licenses and Certifications Required:
1. Valid Medical Doctor License.
Licenses and Certifications Preferred:
1. Maintenance of at least one Medical Board Certification.
Hackensack Meridian Health is committed to maintaining a safe environment for its employees and patients.
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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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Hackensack, New Jersey, United States Hackensack Meridian Health Full timeOverview 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...
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