Medical Doctor Utilization Management Specialist
6 days ago
We are seeking a highly skilled Medical Doctor to join our Utilization Management Department as a Physician Advisor. In this role, you will collaborate with our utilization management, quality, and clinical teams to ensure that all patients receive medically necessary, clinically appropriate, and high-quality care.
Key Responsibilities:
- Perform medical necessity reviews to determine the clinical appropriateness of care and examine resource utilization.
- Conduct peer-to-peer discussions with payors' medical directors to obtain inpatient authorization when necessary.
- Communicate with clinical teams to ensure accurate documentation and act as a resource for staff to identify opportunities for process improvement.
- Participate in the FFS Medicare two-midnight rule compliance program and incorporate regulatory, legal, and contractual issues into daily work.
Requirements:
- Must hold a New York Medical Doctor License and current registration.
- A minimum of 5 years' inpatient acute care clinical experience.
- Working knowledge of CMS's two-midnight rule, Medicare coverage criteria, New York State facility performance data, and associated regulatory and payer requirements.
- Experience in population health, clinical integration, and cost containment activities, along with managed care experience and utilization management.
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