Physician Advisor
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Job Description
Physician Advisor conducting clinical reviews and utilization guidance for Med-Metrix. Improving medical necessity decisions, documentation, coding, and denial prevention.
Responsibilities:
- Conduct physician-to-physician reviews for medical necessity, level of care, and denial prevention/appeals
- Support utilization review and case management teams with complex clinical decision-making
- Communicate with the Physician Advisory team, hospital physicians, care coordination, and utilization management staff to promote evidence-based care and documentation
- Assist in improving documentation related to ICD coding, severity of illness, risk of mortality, and DRG assignment
- Keep current with CMS and MCG evidence-based guidelines
- Maintain compliance with legal, regulatory, accreditation, and payer partner requirements
- Meet productivity and quality standards within established time requirements
- Attend required training and meetings
- Participate in peer review as needed
- Protect and disclose patients’ PHI in accordance with HIPAA standards
- Limit PHI access to the minimum necessary for assigned duties
- Perform other duties as assigned
Requirements:
- MD or DO with an active, unrestricted medical license
- US Board Certified in a recognized specialty
- Minimum of 1 year of payer or provider-side utilization review, or active ACPA and/or ABQUARP certification
- Basic technical skills with hospital EMRs
- Strong knowledge of utilization management, medical necessity, and payer regulations
- Familiarity with MCG/InterQual placement status criteria preferred
- Membership in the American College of Physician Advisors (ACPA) preferred
- Ability to effectively present information, both formally and informally
- Proficiency in Microsoft Office Suite
- Strong interpersonal and communication skills
- Strong problem-solving and creative skills, with sound judgment and ability to make decisions based on accurate and timely analyses
- High integrity and dependability, with a strong sense of urgency and results orientation
- Excellent written and verbal communication skills
- Ability to use a smartphone or electronic device capable of downloading applications for multifactor authentication and security purposes
- Ability to follow directions, collaborate with others, and handle stress
Benefits:
- Multifactor authentication and security support via a required smartphone or electronic device
- Compliance with HIPAA, information security, legal, regulatory, accreditation, and payer partner policies
- Equal employment opportunity protections
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