Medical Doctor Utilization Management Specialist

5 days ago


Yonkers, New York, United States Smith Arnold Partners Full time
Medical Doctor Utilization Management Physician Advisor

We are seeking a highly skilled Medical Doctor to join our Utilization Management Department as a Physician Advisor. As a key member of our team, you will work collaboratively 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 of patient records.
  • Act as a resource to clinical, care management, and non-clinical 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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