Audit/Medical Review Physician
 

The medical review physician should review the documentation submitted and identify the following content that support’s the patient’s appropriateness, including any higher level of care billed, if applicable: clinical history and physical findings, documentation of functional status and symptoms, and pertinent changes in plans of care. The medical review physician should review certification / recertification worksheets and narratives, plans of care review, and interdisciplinary team notes to ensure that they collectively reflect and support the patient’s hospice benefit appropriateness. Where there are inconsistencies or omissions, the physician should provide explanation or suggest correction.   The medical review physician should prepare a summary (demographics, time of admission, course of care under review, disposition, statement of eligibility) outlining the patient’s hospice benefit appropriateness and focus on bringing the claim reviewer’s attention to the specific documentation that supports the patient’s hospice eligibility, as well as any additional supportive documentation that may be added at the time of the appeal. Where appropriate, the medical review physician should reference evidence based guidelines or journal articles.  If a detailed claim denial explanation was provided in the claim review summary, the medical review physician should: 1. Verify whether the claim denial code is legitimate for the level of care on date(s) in contention, 2. Identify if there are discrepancies between the claim review explanation and supporting documentation, 3. Address each claim denial reason with the necessary explanation and supportive documentation, 4. Identify whether there are additional chart documents not included in the first submission that establish hospice appropriateness.  The chart review note submitted by medical review physician in preparation for submission of appeal, should summarize findings recorded elsewhere in the record and not conflict with daily progress notes. New information should be supported by additional documentation that has been accessed from the chart.  Performs related duties as required. This position description in no way states or implies that these are the only duties to be performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Experience:

 

Education: 

Board eligible / certified in Hospice and Palliative Medicine, Family Medicine, Internal Medicine, or other related specialty with a working knowledge of the principles of palliative medicine and symptom management. Completion of designated application and verification of credentials and qualifications.

 

Certification & Licensure:

Licensed to practice medicine or osteopathy in the state in which the program is operating.

 

Physical Requirements:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.

 

SPECIAL INSTRUCTIONS TO CANDIDATES

EOE/AA M/F/D/V