Major Responsibilities:

Utilization Management:Provides second level review for level of care determination for cases referred by UM staff.Review cases, as appropriate, to identify potential for delay in care delivery that can impact transition to next lower level of care or extend LOS. Discuss case with UM/CM staff, site physician advisor, and/or attending physician, as neededDaily review of cases referred by UM staff and provides guidance, documents outcomes, and follows up as needed with staff. Discuss cases with site physician advisor and/or attending physician, as neededWorks with contracting providing recommendations regarding review process and policies with payersReviews cases as part of the Medicare Inpatient short stay review process to evaluate compliance with the CMS “Two Midnight Rule”Reviews cases where a peer to peer has been offered by a payer and completes the peer-to-peer discussion if needed Denials / Appeals:Acts as a liaison with payers to facilitate approvals and prevent denialsAssists with the denial management process and related process. improvement opportunities for the system and sitesWorks with denial specialists on developing a response to payer denialsParticipates in discussions with payers to assist in reversing denials including Peer to Peer discussionsProvides education to physicians, other clinicians, and UM/CM/Denials/ Revenue recovery staff related to regulatory requirements, appropriate utilization, and payer behaviors.Serves as consultant and resource to Site Medical Directors of Care Management / Physician Advisors and attending physicians regarding their decisions relative to appropriateness of hospitalization, level of care selection, and continued stay cases.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 KRA 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 and denials in establishing a culture of open communication, accountability and timely decision making within the division.

Licensure, Registration, and/or Certification Required:

Medicine and Surgery, MD-DO license issued by the state in which the team member practices, andPhysician board certification issued by an appropriate board recognized by the American Board of Medical Specialties or the American Osteopathic Association.Eligibility for active membership on the hospital’s medical staffCurrent physician advisor certification thru ABQUARP (Certification in Health Care Quality and Management), American College of Physician Advisors (ACAP-C) or Association of Physician Leadership in Care Management (Care Management Physician Certification).  If not certified on hire date, certification will be required within 2 years of hire date.

Education Required:

Doctorate Degree in Medicine or Doctor of Osteopathic Medicine

Experience Required:

Typically requires 5 years of experience in utilization management and/or clinical practice.Salary Range is typically between $280,000 and $312,000 annually .

Knowledge, Skills & Abilities Required:

Skills in diplomacy and negotiation in peer interactions regarding utilization issues.Demonstrates knowledge of medical necessity criteria and ICD-10 guidelines.Maintains current knowledge of federal, state and payer regulatory and contract requirements.Ability to utilize computer based medical record and other electronic tools in conduction reviews, reviewing data, and documenting as appropriate to role.Strong analytical and decision-making skills.Strong leadership and interpersonal skills. Ability to communicate effectively.

Physical Requirements and Working Conditions:

This position requires travel, therefore, will be exposed to weather and road conditions. Operates all equipment necessary to perform the job.Exposed to a normal office environment.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.