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Utilization Review Consultant

Meridian Health

This is a Full-time position in Hackensack, NJ posted April 8, 2021.

OverviewThe 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. ResponsibilitiesEssential Generic Job Functions (List in order of importance):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. Inpatientc. Liaison to the Medical Staff supporting Utilization Management Committee processes d. Hospital Based Appeals Managemente. Provides guidance and interpretation on issues of medical appropriateness and level of care needs2. Liaison between medical staff and other clinical staff by being:a. Excellent communicatorb. Broad spectrum clinical knowledge basec. Expert resource related to admission criteria, observation status criteria and documentation requirements3. Education/Advisorya. Physician Educatori. Provide formal educational lectures and engage in frequent informal meetingsii. Retrospective Medical Record Documentation Reviewiii. Clarifying ambiguous or conflicting documentationiv. Target DRGs Reviewsv. Use of case manager as a resource4. 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 Comorbidities5. (CC) categories documentation and identificationa. Tools to assist with care coordination decision makingb. Liaison with 3rd party payers as needed6. Leadership, Staff Management and Organizational Strategya. Development & implementation of Utilization Management strategies to assure appropriate health care delivery in appropriate settingb. 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 objectivesd. Interfaces with Clinical Team in regards to Utilization Management and evidence based medicinee. Provides professional support to the functions within the Utilization Management Departmentf. Provides periodic written and verbal reports and updates regarding Utilization Management as requiredg. Promotes and supports a working environment consistent with the values-based culture of Hackensack Meridian Healthh. Supports the Revenue Cycle Clinical Team in planning, coordinating and executing protocols, policies and strategies within the departmenti. Partners with Senior Leadership and other stakeholders to achieve strategic objectives through successful implementation/completion of strategic initiativesj. Develop strategies across all functional departments to reduce clinical denials by:i. Peer-to Peer (P2P) – Concurrent appealsii. Written Concurrent appeals iii. Recovery Audit Contractors & levels of appealiv. Root cause analysis & trendsv. Participation in Managed Care Contracting & distribution of contract terms where appropriate7. Utilization Review Processa. 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 Technologya. Partners with Operations and Senior Leadership to assess and implement technology b. Collaborates with the CDI team as needed QualificationsKnowledge, Education and Skills 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.Required Certification/Licensing:1. Current New Jersey Medical License.Preferred Certification/Licensing:1. Maintains at least one Medical Board Certification. Our Network 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.