Physician Utilization Review Specialist Per Diem

Overview The Senior Utilization Review 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 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. Weekend and holiday coverage required as needed based on dept needs. ResponsibilitiesEssential Job Functions:Regulatory compliancea. Provides direction and support regarding CMS & NJDOH regulations governing Utilization Management & Clinical documentation.b. Oversight for accurate patient status determinations - OBS vs. Inpatientc. Liaison to the Medical Staff supporting Utilization Management Committee processesd. Hospital Based Appeals Managemente. Provides guidance and interpretation on issues of medical appropriateness and level of care needsLiaison between medical staff and other clinical staff by being:a. Excellent communicatorb. Broad spectrum clinical knowledge basec. Expert resource related to admission criteria, observation status criteria and documentation requirementsEducation/Advisorya. Physician Educatorb. Provide formal educational lectures and engage in frequent informal meetingsc. Retrospective Medical Record Documentation Reviewd. Clarifying ambiguous or conflicting documentatione. Target DRGs Reviewsf. Use of case manager as a resourceUses 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(CC) categories documentation and identificationa. Tools to assist with care coordination decision makingb. Liaison with 3rd party payers as neededLeadership, Staff Management and Organizational Strategya. Development & implementation of Utilization Management strategies to assure appropriatehealth care delivery in appropriate settingb. Provides guidance & support for executing targeted Utilization Management Strategies and relevant Improvementc. 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 objectivesd. Interfaces with Clinical Team in regards to Utilization Management and evidence based medicinee. Provides professional support to the functions within the Utilization Management Departmentf. Provides periodic written and verbal reports and updates regarding Utilization Management as requiredg. Promotes and supports a working environment consistent with the values-based culture of Hackensack Meridian Healthh. Supports the Revenue Cycle Clinical Team in planning, coordinating and executing protocols, policies and strategies within the departmentI. Partners with Senior Leadership and other stakeholders to achieve strategic objectives through successful implementation/completion of strategic initiativesj. Develop strategies across all functional departments to reduce clinical denials by:I. Peer-to Peer (P2P) Concurrent appealsii. Written Concurrent appealsiii. Recovery Audit Contractors & levels of appealiv. Root cause analysis & trendsv. Participation in Managed Care Contracting & distribution of contract terms where appropriateUtilization Review Processa. 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)Electronic Health Record (EHR)/Other Technologya. Partners with Operations and Senior Leadership to assess and implement technologyb. Collaborates with the CDI team as neededOther duties as assigned QualificationsEducation, 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 levelsof 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 ofregulatory requirements relative to performing status determinations and Peer to Peer denialinteractions with medical directors of third-party payers.Contacts:Regular contact with Medical Center personnel, patients and visitors. CompensationMinimum rate of $5,356 AnnuallyHMH is committed to pay equity and transparency for our team members. The posted rate of pay in this job posting is a reasonable good faith estimate of the minimum base pay for this role at the time of posting in accordance with the New Jersey Pay Transparency Act and does not reflect the full value of our market-competitive total rewards package. The starting rate of pay is provided for informational purposes only and is not a guarantee of a specific offer. Posted hourly rates may be stated as an annual salary in the offer and posted annual salaries may be stated as an hourly rate in the offer, depending on the level and nature of the job duties and credentials of the candidate. The base compensation determined at the time of the offer may be different than the posted rate of pay based on a number of non-discriminatory factors, including but not limited to: Labor Market Data: Compensation is benchmarked against market data to ensure competitiveness. Experience: Years of relevant work experience. Education and Certifications: Level of education attained, including specialized certifications, credentials, completed apprenticeship programs or advanced training. Skills: Demonstrated proficiency in relevant skills and competencies. Geographic Location: Cost of living and market rates for the specific location. Internal Equity: Compensation is determined in a manner consistent with compensation ranges for similar roles within the organization. Budget and Grant Funding: Departmental budgets and any grant funding associated with the job position may impact the pay that can be offered. Some jobs may also be eligible for performance-based incentives, bonuses, or commissions not reflected in the starting rate. Certain positions may also be eligible for shift differentials for work performed on evening, night, or weekend shifts. In addition to our compensation for full-time and part-time (20+ hours/week) job positions, HMH offers a comprehensive benefits package, including health, dental, vision, paid leave, tuition reimbursement, and retirement benefits. HACKENSACK MERIDIAN HEALTH (HMH) IS AN EQUAL OPPORTUNITY EMPLOYER All qualified applicants will receive consideration for employment without regard to age, race, color, creed, religion, sex, sexual orientation, gender identity or expression, pregnancy, breastfeeding, genetic information, refusal to submit to a genetic test or make available to an employer the results of a genetic test, atypical hereditary cellular or blood trait, national origin, nationality, ancestry, disability, marital status, liability for military service, or status as a protected veteran.