Physician Advisor Denials Management

Overview:

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.

This is a remote position.

Summary

The Utilization Management Physician Advisor II conducts clinical case reviews referred by case management staff and/or other health care professionals to meet regulatory requirements and in accordance with the hospital’s objectives for assuring quality patient care and effective and efficient utilization of health care services. This position will be a part of the specialized Denials Management team. This individual meets with case management and health care team members to discuss selected cases and make recommendations for care as well as interacting with medical staff members and medical directors of third- party payers to discuss the needs of patients and alternative levels of care. The PA performs denials management and prevention in accordance with the organization’s goals and expectations. This individual reviews cases for clinical validation, performs peer-to-peer discussions and participates in appeal letter writing. The PA acts as a consultant to, and resource for, attending physicians regarding their decisions relative to appropriateness of hospitalization, clinical documentation, continued inpatient stay, and use of healthcare resources. The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations. The PA helps facilitate training for the physicians. The PA must demonstrate interpersonal and communication skills and must be clear, concise and consistent in the message to all constituents.

Key Responsibilities

• Conducts medical record review in appropriate cases for medical necessity of inpatient admission, need for continued hospital stay, adequacy of discharge planning and quality care management. 
• Understands the intricacies of ICD-9-CM, ICD-10-CM/PCS, MS-DRG, APR-DRG, and the Medicare Inpatient Prospective Payment System (IPPS) to make medical determinations on severity of illness, acuity, risk of mortality, and communicate with treating physicians in cooperation with the utilization team and health information personnel
• Conducts peer-to-peer reviews with payer medical directors to discuss and advocate for the medical necessity of denied treatments, services, or hospitalizations. Presents clinical rationale, addresses concerns raised by the payer, and provides additional context to overturn denials before escalation to formal appeal.
• Reviews and analyzes denied claims to determine validity and identify opportunities for overturning inappropriate denials. Leads the appeals process by providing clinical expertise, crafting compelling appeal letters, and ensuring the submission of necessary documentation.
• Serves as a liaison between the national care management team, medical staff, and medical executives to encourage physician cooperation and understanding of documentation importance 
• Assists in communications of internal physician advisor services in the hospital newsletters and other communication vehicles to further educate the medical staff
• Communicates feedback on program results to facility leadership (i.e. CMO, Care Management Directors, Quality Directors)
• Provides feedback and education to the Care Management and Clinical Documentation Departments through written and verbal communication as well as appropriate tracking and trending for process improvement efforts.
• Attends and participates in facility committee meetings such as Joint Operating Committee (JOC), as requested by Utilization Management or Care Management
• Contacts Attending Physicians: Makes face-to-face and telephonic/electronic contacts and presentations to all medical staff physicians and potential physician groups introducing referral services, new products and present product offerings.
• Conducts Peer to Peer discussions with payers as needed: Acts as a liaison and coordinator with operations for physicians. Attends applicable committee meetings, such as a Joint Operating Committee (JOC), as requested by Utilization Management or Managed Care: Works with the Care Management Director and staff to facilitate client profiles, clinical service utilization and support for revenue management activities.

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
• Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills

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