Sr Utilization Review Spec FT HUMC

Overview

The Utilization Review Physician 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.

Responsibilities

Essential Job Functions:
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,
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)

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
9. Other duties as assigned

Qualifications

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.
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 of
regulatory requirements relative to performing status determinations and Peer to Peer denial
interactions with medical directors of third-party payers.

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.

Our Network

Hackensack Meridian Health (HMH) is a Mandatory Influenza Vaccination Facility

As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.