**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.** **Job ID** _2024-155583_ **Department** _Utilization Review_ **Site** _Hackensack University Med Cntr_ **Job Location** _US-NJ-Hackensack_ **Position Type** _Full Time with Benefits_ **Standard Hours Per Week** _40_ **Shift** _Day_ **Shift Hours** _varies_ **Weekend Work** _Weekends as Needed_ **On Call Work** _No On-Call Required_ **Holiday Work** _As Needed_