Physician Advisor, Utilization Management
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Alignment HealthHealthcare
United StatesFull-TimeManager
Salary198,219 - 297,329 USD per year
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Job Details
- Experience
- Minimum of 3 years of experience in hospital-wide or skilled nursing facility position involving clinical care, quality management, utilization and case management, or medical staff governance
Requirements
- Current, non-restricted medical license in the state of California.
- Completion of medical school and specialty residency.
- Minimum of 3 years of experience in hospital-wide or skilled nursing facility clinical care, quality, or utilization/case management.
- Knowledge of current medical literature and research methodology.
- Familiarity with healthcare delivery systems and reimbursement issues.
- Ability to perform mathematical calculations and simple statistics.
- Advanced problem-solving and reasoning skills.
- Effective written and oral communication skills.
- Experience as a Physician Advisor is preferred.
- Board certification is preferred.
- Subspecialty or post-residency fellowship is preferred.
Responsibilities
- Process second level reviews in compliance with Medicare/CMS (NCD, LCD) and Milliman guidelines.
- Provide appropriate level of care classifications and conduct continued stay reviews.
- Act as a liaison between medical staff, utilization review, and 3rd party payers.
- Review the entire claim denial process, including Appeals and Grievances.
- Collaborate with the Interdisciplinary Team to develop case management protocols and provide oversight for NP/PA training.
- Serve as Clinical Leader for HEDIS and STARS projects and Clinical Advisor for HCC and RAF.
- Chair the Medical Quality Committee and provide oversight for Chronic Disease Management programs.
- Work with Extensivists and Middle Level Practitioners to reduce length of stay, readmissions, and ER overutilization.
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