Clinical Utilization & Denials Leader

Riverside Healthcare; Kankakee (IL); On-site; USD 150,000 - 190,000; Full time

Job summary

Riverside Medical Group in Kankakee, IL, seeks a Physician Advisor for inpatient utilization management to optimize care, ensure regulatory compliance, and support payer requirements.

Reporting to leadership and partnering with Care Management, Utilization Review, Revenue Cycle, you will guide documentation, level of care decisions, and denial management, including appeals, under CMS rules.

Qualifications

• MD or DO with unrestricted medical license in Illinois.
• Minimum 5 years clinical hospital experience.
• Solid foundation in utilization management and hospital operations.

Responsibilities

• Make recommendations on level of care, initial and secondary reviews, as requested by case management.
• Improve documentation to reflect medical necessity and regulatory/payer requirements.
• Collaborate with providers to clarify rationale for services and reduce denials.
• Lead denial management and perform peer-to-peer appeals as needed.
• Apply InterQual, MCG or other criteria to support appropriate billing.

Job description

Riverside Medical Group in Kankakee, IL, seeks a Physician Advisor for inpatient utilization management to optimize care, ensure regulatory compliance, and support payer requirements.

Reporting to leadership and partnering with Care Management, Utilization Review, Revenue Cycle, you will guide documentation, level of care decisions, and denial management, including appeals, under CMS rules.