Physician Advisor - Utilization Management

Summary:

The Physician Advisor is responsible for writing and submitting clinical denial appeals, performing concurrent reviews and peer-to-peer discussions with payer representatives and educating clinical staff on process improvement opportunities to increase reimbursements and reduce clinical denials. This role utilizes clinical knowledge & experience, information science, and interpersonal skills to support and represent the optimal denials recovery and prevention processes identified with all medical, clinical and ancillary departments. This role researches and responds to denials in a timely fashion and identifies trends and responds to the trends by recommending changes in practice and/or documentation of the providers to promote a reduction in the denials trends. This role acts as a bridge between providers and other staff to improve clinical documentation, utilization review, and claim denials management. This position also serves as subject matter expert, providing clinical expertise and business direction in support of medical management programs, promoting the delivery of high quality, patient focused and cost effective medical care.

Prime Healthcare is seeking an MD with five or more years Clinical Physician experience. Must have knowledge of CMS Regulations as well as expertise with Interqual and/or Milliman Disease Management Ideologies. Must have experience with peer to peer reviews. Experience working with EMR’s including Meditech and EPIC.

Required qualifications:

·         Current MD License in the State of Practice

·         Five or more years Clinical Physician Experience

·         Two to Five Years Utilization Review, Denial Management, Case Management or related experience.

·         Knowledge of CMS Regulations

·         Must have expertise with Interqual and/or Milliman Disease Management Ideologies

·         2-4 years of current experience with reimbursement methodologies

·         Experience with peer to peer review of clinical denials.

·         Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement.

·         Experience working with varied EMRs including Meditech and EPIC

Preferred qualifications:

·         Interqual Certification

·         CDC or equivalent Coding Certification

·         Certification in Clinical Documentation Improvement