6 Sr Utilization Review Spec-Physician FT HUMC Jobs in Hackensack, NJ
Hackensack Meridian Health is Hiring a Sr Utilization Review Spec-Physician FT HUMC Near Hackensack, NJ
Responsibilties
- Regulatory compliance
- Provides 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 by being:
- 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
iii. Clarifying ambiguous or conflicting documentation
iv. Target DRGs Reviews
- Use of case manager as a resource
- 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
- (CC) categories documentation and identification
- Tools to assist with care coordination decision making
- Liaison with 3rd party payers as needed
- Leadership, Staff Management and Organizational Strategy
- Development & implementation of Utilization Management strategies to assure appropriate health care delivery in appropriate setting
- Provides guidance & support for executing targeted Utilization Management Strategies and relevant Improvement
- 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
- Interfaces with Clinical Team in regards to Utilization Management and evidence based medicine
- Provides professional support to the functions within the Utilization Management Department
- Provides periodic written and verbal reports and updates regarding Utilization Management as required
- Promotes and supports a working environment consistent with the values-based culture of Hackensack Meridian Health
- Supports the Revenue Cycle Clinical Team in planning, coordinating and executing protocols, policies and strategies within the department
- Partners with Senior Leadership and other stakeholders to achieve strategic objectives through successful implementation/completion of strategic initiatives
- Develop strategies across all functional departments to reduce clinical denials by:
- Peer-to Peer (P2P) Concurrent appeals
iii. Recovery Audit Contractors & levels of appeal iv. Root cause analysis & trends
- Participation in Managed Care Contracting & distribution of contract terms where appropriate
- 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
- 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.
- Medical Doctor License.
- Maintains at least one Medical Board Certification.
Job Summary
Full Time
Ambulatory Healthcare Services
$139k-176k (estimate)
06/02/2024
07/24/2024
hackensackmeridianhealth.org
OAKHURST, NJ
50 - 100
2016
ROSE F HAYET MD
$10M - $50M
Ambulatory Healthcare Services
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About Hackensack Meridian Health
Hackensack Meridian Health is a leading not-for-profit health care organization that is the largest, most comprehensive and truly integrated health care network in New Jersey, offering a complete range of medical services, innovative research and life-enhancing care. Hackensack Meridian Health comprises 17 hospitals from Bergen to Ocean counties, which includes three academic medical centers Hackensack University Medical Center in Hackensack, Jersey Shore University Medical Center in Neptune, JFK Medical Center in Edison; two childrens hospitals - Joseph M. Sanzari Childrens Hospital in Hacke...nsack, K. Hovnanian Childrens Hospital in Neptune; nine community hospitals Bayshore Medical Center in Holmdel, Mountainside Medical Center in Montclair, Ocean Medical Center in Brick, Palisades Medical Center in North Bergen, Pascack Valley Medical Center in Westwood, Raritan Bay Medical Center in Old Bridge, Raritan Bay Medical Center in Perth Amboy, Riverview Medical Center in Red Bank, and Southern Ocean Medical Center in Manahawkin; a behavioral health hospital Carrier Clinic in Belle Mead; and two rehabilitation hospitals - JFK Johnson Rehabilitation Institute in Edison and Shore Rehabilitation Institute in Brick. Additionally, the network has more than 500 patient care locations throughout the state which include ambulatory care centers, surgery centers, home health services, long-term care and assisted living communities, ambulance services, lifesaving air medical transportation, fitness and wellness centers, rehabilitation centers, urgent care centers and physician practice locations. Hackensack Meridian Health has more than 35,000 team members, and 7,000 physicians and is a distinguished leader in health care philanthropy, committed to the health and well-being of the communities it serves.
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