Physician Advisor Denials Management Specialist
3 weeks ago
The Physician Advisor Denials Management Specialist will conduct clinical case reviews referred by case management staff and/or other healthcare professionals to meet regulatory requirements and in accordance with the hospital's objectives for assuring quality patient care and effective and efficient utilization of healthcare services.
Key Responsibilities- Conduct medical record reviews in appropriate cases for medical necessity of inpatient admission, need for continued hospital stay, adequacy of discharge planning, and quality care management.
- Understand the intricacies of ICD-9-CM, ICD-10-CM/PCS, MS-DRG, APR-DRG, and the Medicare Inpatient Prospective Payment System (IPPS) to make medical determinations on severity of illness, acuity, risk of mortality, and communicate with treating physicians in cooperation with the utilization team and health information personnel.
- Conduct peer-to-peer reviews with payer medical directors to discuss and advocate for the medical necessity of denied treatments, services, or hospitalizations.
- Present clinical rationale, address concerns raised by the payer, and provide additional context to overturn denials before escalation to formal appeal.
- Reviews and analyzes denied claims to determine validity and identify opportunities for overturning inappropriate denials. Leads the appeals process by providing clinical expertise, crafting compelling appeal letters, and ensuring the submission of necessary documentation.
- MD or DO
- Minimum 3 years of experience as a Physician Advisor
- Minimum 5 years of experience in Clinical Practice
- Experience performing Peer to Peer Reviews
- Experience submitting written and verbal appeals
- Unrestricted license in field of practice in the state of California
- Broad-based knowledge regarding clinical practice
- Broad knowledge base with trust and respect of medical staff physicians
- In-depth knowledge of CMS regulations, including understanding of the 2-midnight rule
- Utilization management experience
- Education in quality and utilization management through continuing medical education programs and self-study
- Knowledge of and practical use of good business English, spelling, arithmetic, practices, and the ability to communicate effectively using written and verbal skills
CommonSpirit Health is an equal opportunity/affirmative action employer.
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