Physician Advisor - Utilization Review, Denials

Fairfax, Virginia
Apr 11, 2023
Jun 10, 2023
Contract Type
Job Description

UR Denials Physician Advisor


  • 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

    • 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.

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