Physician Advisor Denials Management Specialist

1 month ago

Sacramento, California, United States CommonSpirit Health Full time

Overview

CommonSpirit Health is a leading healthcare organization that is committed to building healthy communities and advocating for those who are poor and vulnerable. As a Physician Advisor Denials Management Specialist, you will play a critical role in ensuring that our patients receive high-quality care while also helping us to optimize our utilization management processes.

Responsibilities

This is a remote position that requires strong clinical expertise and excellent communication skills. As a Physician Advisor Denials Management Specialist, you will be responsible for conducting medical record reviews to determine medical necessity, conducting peer-to-peer reviews with payer medical directors, and analyzing denied claims to identify opportunities for overturning inappropriate denials. You will also serve as a liaison between our national care management team, medical staff, and medical executives to encourage physician cooperation and understanding of documentation importance.

Key Responsibilities

  • Conduct medical record reviews to determine medical necessity and appropriateness of hospitalization
  • Conduct peer-to-peer reviews with payer medical directors to discuss and advocate for the medical necessity of denied treatments, services, or hospitalizations
  • Analyze denied claims to determine validity and identify opportunities for overturning inappropriate denials
  • Serve as a liaison between our national care management team, medical staff, and medical executives to encourage physician cooperation and understanding of documentation importance
  • Communicate feedback on program results to facility leadership
  • Provide feedback and education to the Care Management and Clinical Documentation Departments through written and verbal communication

Qualifications

Required:

  • 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

Pay Range

$88.46 - $141.54 /hour

We are an equal opportunity/affirmative action employer.

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