Medical Necessity Specialist

2 weeks ago


Vestavia Hills, Alabama, United States Highmark Health Full time
Job Summary

We are seeking a highly skilled Physician Advisor to join our team at Highmark Health. As a key member of our Clinical Resource Management Committee, you will play a critical role in evaluating the medical necessity and appropriateness of healthcare services.

Key Responsibilities
  • Evaluate medical necessity and appropriateness of admission to the hospital, utilization of observation status, and ancillary services.
  • Work with admitting physicians, Case Management, and other hospital personnel to ensure optimal patient care.
  • Provide medical expertise, advice, and support to the Case Management Department.
  • Develop and implement strategies to reduce length of stay and improve quality of care.
  • Collaborate with coding and clinical documentation specialists to ensure accurate and compliant documentation.
  • Participate in payer contract reviews to determine criteria for avoiding unnecessary denials.
Requirements
  • Doctorate in Medicine (MD) or Doctor of Osteopathic Medicine (DO)
  • 5 years of clinical practice experience in a hospital setting
  • Board Eligible or Board Certified in a relevant specialty
  • PA License
  • Preferred: Physician Advisor experience in a clinical setting, cross-functional teams, large health systems, and integrated payer/provider networks
What We Offer

As a Physician Advisor at Highmark Health, you will have the opportunity to work with a talented team of healthcare professionals, contribute to the development of clinical policies and procedures, and make a meaningful impact on patient care.



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