• Perform timely and compliant medical necessity reviews, providing clear documentation of the pertinent details of the case to satisfy regulatory requirements and directly communicating any necessary
• Facilitate denials management through review of selected cases, conducting peer to peer discussion with third party payers as appropriate, and assisting with appeals letters
• Work closely with hospital leadership, medical staff, and hospital ICM leaders to support system CPIs and initiatives
• Partner with hospital leadership, physician advisors, and corporate administration to standardize best practices in utilization management and care progression.
• Conducts medical record review in cases in question for medical necessity of admission, need for continued hospital stay, adequacy of discharge planning and quality care management.
• Contacts attending physicians and/or consultants as needed to seek clarification or additional information, documentation requirements, discuss alternate level of care options, minimize denials, relieve bed capacity constraints and expedite care across the continuum
• Supports case management department staff as it relates to clinical decisions, escalation of patient care issues and management of long LOS patients.
• Assists with level of care and length of stay management, assists with the denial management process, reviews and makes suggestions related to resource and service management, assists staff with the clinical review of patients, determines if professionally recognized standards of quality care are met
• Ensure compliance with CMS regulations, payer requirements, and internal policies related to utilization and medical necessity.
• Performs other duties as assigned to support overall effectiveness of department and organization.

Education: 

• Completion of Medical Doctorate or Doctor of Osteopathy degree from an accredited medical school
• Completion of an accredited residency training program

Experience:  N/A

Certification:  Board certification in specialty required at time of hire

License: 

• Active and unrestricted state of Arizona medical license 

Knowledge, Skills, and Abilities:

• Possess or acquire a working knowledge of CMS regulatory guidance and requirements as they pertain to UR and site of service decisions
• Possess a working knowledge of clinical documentation integrity, hospital billing and coding processes and guidelines, case mix index, and DRG assignments
• Familiarity with standard published leveling criteria such as MCG/InterQual and ability to apply professional judgment and patient-specific variables as may be necessary or justifiable

Education:  N/A

Experience:  Minimum of 5 years of clinical experience, hospital clinical experience

Certification:  N/A

License:  N/A

Knowledge, Skills, and Abilities: N/A

• Ability to sit from 6-7 hours daily at a desk and/or computer terminal