Physician Utilization Review Specialist

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 HackensackUMC. 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.

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 )

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

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.

Licenses and Certifications Required:

1. Medical Doctor License.

Licenses and Certifications Preferred:

1. Maintains at least one Medical Board Certification.