Physician Advisor - Utilization Review, Denials
Job Description
UR Denials Physician Advisor
MAJOR RESPONSIBILITES
In peer-to-peer discussions at the discretion of the Denials Physician Advisor
UR Denials Physician Advisor
MAJOR RESPONSIBILITES
- Utilization Management/Denials and Reconsiderations:
- Provides second level review for level of care determination (post-discharge denials) referred by UR Denials RNs.
- Assists the denial RNs in developing a response to payer denials (Reconsiderations).
- Reviews cases where a peer to peer has been offered by a payer and completes the peer-to-peer discussion if needed. Primary or subspecialty consultants may be asked to participate
In peer-to-peer discussions at the discretion of the Denials Physician Advisor
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- Reviews and participates in case reviews as part of the Medicare Inpatient short stay review process to evaluate compliance with the CMS “Two Midnight Rule”
- Acts as a liaison with payers to facilitate approvals and prevent denials
- Assists with the denial management process and related process. improvement opportunities for the system and sites
- Works with contracting providing recommendations regarding review process and policies with payers
- Provides education to physicians, other clinicians, and UM/CM/Denials/ Revenue recovery staff related to regulatory requirements, appropriate utilization, and payer behaviors.
- Facilitates internal and external relationships with all physicians and constituents of CM/UM and revenue cycle.
- Conducts education sessions utilizing reports with clinical and financial information to mentor the site physician advisors on site KPI goals and process measures and with revenue cycle staff as appropriate.
- Demonstrates knowledge of nationally recognized medical necessity criteria and ICD-10 guidelines. Maintains current knowledge of federal, state and payer regulatory and contract requirements. Attends continuing education sessions pertaining to utilization and quality management.
- Establishes a culture of collaboration and integration that enhances the provision of excellent, safe, and reliable patient care.
- Assists the medical director and leaders of CM, UM, revenue integrity, compliance and denials in establishing a culture of open communication, accountability and timely decision making within the division.