Medical Necessity Expert
7 days ago
Company Overview
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. We are committed to helping individuals access quality healthcare services and improving health outcomes.
Job Description
The Physician Advisor will play a crucial role in driving performance across our organization by communicating with hospital physicians and utilization management staff at client hospitals to champion best practices for evidence-based care and its documentation. This position drives performance across our organization by optimizing the use of Optum services.
Key Responsibilities
- Conduct second-level medical necessity/compliance status reviews for all payor types.
- Meet with case management, utilization management, social work, and other healthcare team members to discuss selected cases and make recommendations regarding patient status through case reviews.
- Interacting with medical staff to discuss medical necessity and concurrent denial cases.
- Act as a consultant for the medical staff regarding their decisions for the appropriate medical necessity status of hospitalized patients and supporting documentation.
- Participate in the claims denial process by conducting peer-to-peer discussions with commercial payor medical directors for cases that have been denied concurrently.
- Coordinate with Optum/OPAS Subject Matter Expert(s) for questions regarding federal, state, and payor regulatory requirements.
Salary
$120,000 - $180,000 per year, depending on experience.
Benefits
We offer a comprehensive benefits package, including medical, dental, and vision insurance, 401(k) matching, and paid time off.
Qualifications
- MD or DO
- Current, unrestricted medical license in Pennsylvania
- Demonstrated ability to build rapport with medical staff and hospital leadership
- Solid computer skills and working knowledge of EMRs
- Receptive to feedback and coaching
- 3+ years of experience in a hospital-based practice setting
Location
This position is based in Pennsylvania, but we encourage remote work options.
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