Per Diem Physician Utilization Review Specialist

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 at Hackensack UMC. These activities include utilization review, hospital reimbursement, clinical compliance, case management, and transitions of care. Weekend and holiday coverage is required as needed based on department needs.

• Regulatory compliance:
  Provides direction and support regarding CMS & NJDOH regulations governing Utilization Management and 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.
• 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.

• Physician Educator:
  Provide formal educational lectures and engage in frequent informal meetings.
• Retrospective Medical Record Documentation Review;
  Clarifying ambiguous or conflicting documentation;
  Target DRG reviews;
  Use of case manager as a resource.

Uses guidelines to evaluate patient status based on length of stay, level of care requirements, 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.

• Development and implementation of Utilization Management strategies to assure appropriate health care delivery in the appropriate setting.
• Provide guidance and support for executing targeted Utilization Management strategies and relevant improvements.
• Collaborate with Clinical Delivery and Operations leadership to support and provide assistance in overall medical management effectiveness, benchmarked utilization and cost management (UM) goals and clinical improvement objectives.
• Interface with Clinical Team regarding Utilization Management and evidence-based medicine.
• Provide professional support to functions within the Utilization Management Department; provide periodic written and verbal reports and updates regarding Utilization Management as required.
• Promote and support a values-based culture; support Revenue Cycle Clinical Team in planning, coordinating and executing department protocols, policies and strategies.
• Partner with Senior Leadership and other stakeholders to achieve strategic objectives through implementation of strategic initiatives.
• Develop strategies across all functional departments to reduce clinical denials by:
  Peer-to-Peer (P2P) concurrent appeals;
  Written concurrent appeals;
  Recovery Audit Contractors & levels of appeal;
  Root cause analysis and trends.
• Participation in Managed Care Contracting & distribution of contract terms where appropriate.

• Subject Matter Expert in the use and application of Utilization Management Criteria (e.g., MCG, Xsolis).
• Supports and participates in pre-admission review, utilization management, and concurrent and retrospective review processes.
• Reviews and facilitates appropriate level of care determinations (Inpatient, Observation, Outpatient / Ambulatory).
• Conducts and supports improvement and outcomes studies related to Utilization Management (self-audits and other auditing activities).

• Partners with Operations and Senior Leadership to assess and implement technology; collaborates with the CDI team as needed.

Education,

Knowledge, Skills and Abilities Required:

• 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…