Physician Advisor
2 weeks ago
The Physician Advisor is a key member of the healthcare organization's leadership team, responsible for ensuring the effective and efficient utilization of healthcare services. This role requires a physician with expertise in clinical practice patterns, resource utilization, medical necessity, and compliance with governmental and private payer regulations.
Responsibilities- Make recommendations on level of care, including initial level of care, secondary review, and as requested by case management.
- Review daily level of care recommendations on cases placed in Observation.
- Participate in the denials management process and lead efforts to optimize denial management.
- Perform peer-to-peer appeals and draft appeal letters for third-party denials where appropriate.
- Apply the 2-midnight rule to Medicare reviews and maintain compliance with Medicare rules as it applies to level of care recommendations.
- Stay current on changes in payer rules, including CMS rules as it pertains to utilization review.
- Recommend and request additional and more complete medical record documentation from providers to support placement status or medical necessity.
- Understand and use InterQual and/or other appropriate criteria.
- Apply medical expertise to assist with appropriate billing for services.
- Provide feedback to Contracting on payer denial patterns where appropriate.
- Facilitate, mentor, and educate other physicians regarding documentation and payer requirements.
- Facilitate, mentor, and educate case management on the utilization review process where appropriate.
- Chair, or assist the Lead Physician Advisor in chairing, the Utilization Committee.
- Doctor of Osteopathic Medicine (DO) or Medical Doctor (MD) degree.
- Minimum 5 years of clinical experience in a hospital setting.
- Possess or develop a solid foundation in the areas of utilization management and hospital operations.
- Possess and maintain an unrestricted medical license in the State of Pennsylvania.
Penn Medicine is dedicated to providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. We believe that the best care for our patients starts with the best care for our employees, and we offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region.
We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.
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