Per Diem UR Physician Specialist

Responsibilities

• Regulatory compliance
• Oversight for accurate patient status determinations - OBS vs. Inpatient
• Liaison to the Medical Staff supporting Utilization Management Committee processes
• Hospital Based Appeals Management
• Education/Advisory Physician Educator
• Retrospective Medical Record Documentation Review
• Clarifying ambiguous or conflicting documentation
• Target DRGs
• 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
• Interfaces with Clinical Team in regards to Utilization Management and evidence based medicine
• Provides professional support to the functions within the Utilization Management Department
• 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
• Reduces clinical denials by: Peer-to Peer (P2P) Concurrent appeals, Written Concurrent appeals, Recovery Audit Contractors & levels of appeal, 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, Xsolis)
• Supports & Participates in pre-admission review, utilization management, and concurrent and retrospective review process
• Conducts and/or supports improvement and outcomes studies related to Utilization Management (Self-Audits & other auditing activities)
• Electronic Health Record (EHR)/Other Technology
• Collaborates with the CDI team as needed

Qualifications

• 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