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

• • 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.