Physician Advisor - Denial Management

Description

Summary:

The Physician Advisor will develop and maintain expertise in assessing inpatient medical necessity, utilization review and assignment of appropriate admission status assignment, care progression, as well as both prevention and management of Medicare, Medicaid, Managed Medicare, and commercial concurrent denials of claims of all types,. This includes, but is not limited to, performing peer to peer discussions with payor medical directors and writing appeal letters to overturn inappropriately denied claims for lack of medical necessity or for readmission for the same diagnosis. The Physician Advisor also organizes and provides targeted education to medical providers, case managers, and other staff regarding appropriate utilization review processes, correct status assignment, and necessary clinical documentation to prevent claim denials. The Physician Advisor also ensures compliance with governmental and private payor regulations for all types of denials.

Responsibilities:

• Closely collaborate with case management and attending physicians, especially Hospitalists and surgeons, to review cases for correct status assignment based on medical necessity using application of nationally recognized UM criteria and then advise changes in status, when necessary, both concurrently and retrospectively.
• Perform concurrent peer-to-peer discussions with payer representatives for denials for medical necessity, with the ability to cite InterQual and/or MCG criteria and current best practices to overturn of the denial. This position can also perform retrospective peer to peer if needed.
• Provide targeted education to providers and other staff regarding correct status assignment and proper chart documentation for denial prevention.
• Assist in Denial reduction by identifying trends in Denials and by improving hospital systems and processes working in collaboration with clinical leadership, Case Management and Denial Management to comply with CMS regulations to reduce likelihood of future payment denials of all types and decrease audits. This includes use of Code 44 for cases inappropriately placed in inpatient status where there was not medical necessity on further review to substantiate an inpatient intensity of treatment.
• Appropriately appeal cases for Nuvance Health when payment is denied from CMS and commercial carriers where inpatient requirements for medical necessity were met if needed.
• Prepare effective written appeals for claims inappropriately denied for lack of medical necessity, lack of adequate clinical information, or DRG readmission within 30 days of discharge, citing literature of best practices and utilizing MCG and InterQual criteria if needed.
• Communicate effectively with providers, representatives from other departments including patient financial services and case management and with senior leadership.
• Fulfills all compliance responsibilities related to the position.
• Performs other duties as assigned.  

Other information:
This position requires a minimum formal education of MD/DO, and minimum of five years job-related experience.

License, Registration, Certification Requirements: Active unrestrictive CT State Physician/Surgeon license.

Desired (not required) criteria include:
Previous physician advisor experience strongly preferred.  Prior experience in hospital Utilization review, and/or MCG-Milliman and InterQual criteria, preferred.

#LI-Hybrid 

Required Skills:
MD with board certification and active license.

Five or more years of inpatient clinical experience.

Able to apply evidenced-based best practices.

Ability to work within departmental timelines.

Strong clinical knowledge.

Strong written and verbal communications skills with all levels of internal and external customers. Team Player/Collaborative.

Working Conditions:

Manual: Some manual skills/motor coord & finger dexterity

Occupational: Little or no potential for occupational risk

Physical Effort: Sedentary/light effort. May exert up to 10 lbs. force

Physical Environment: Generally pleasant working conditions

Company: Nuvance Health

Org Unit: 1768

Department: Denial Mgmt

Exempt: Yes

Salary Range: $0.00 - $1000.00 Hourly