Physician Advisor: Medical Necessity & Denials Expert

Sentara Healthcare Inc; Virginia Beach (VA); On-site; USD 180,000 - 240,000; Full time

Job summary

Sentara Healthcare Inc in Virginia Beach seeks a Physician Advisor to perform timely and compliant medical necessity reviews and assist with denials management within the centralized Utilization Review process for Sentara hospital facilities.

The role entails close collaboration with Clinical Revenue Cycle, UR, hospital leadership and medical staff, providing education to attending physicians on regulatory requirements and documentation standards to support hospital status and billing.

Qualifications

• Excellent customer service and interpersonal skills.
• Working knowledge of CMS regulatory guidance and requirements as they pertain to UR and site of service decisions (Required)
• Working knowledge of clinical documentation integrity, hospital billing and coding processes and guidelines, case mix index, and DRG assignments (Required)
• Familiarity with standard published leveling criteria such as MCG/Interqual and ability to apply professional judgment and patient-specific variables as may be necessary or justifiable (Required)
• Familiarity with (Hospital) organization and case management operations (Required)
• Strong technical/computer skills and working knowledge of the system’s EMR (Required)
• Ability to present information clearly (Required)
• Demonstrate flexibility, teamwork, and a collaborative leadership style (Required)

Responsibilities

• Perform timely and compliant medical necessity reviews, providing clear documentation of the pertinent details of the case to satisfy regulatory requirements and directly communicating any necessary
• Facilitate denials management through review of selected cases, conducting peer to peer discussion with third party payers as appropriate, and assisting with appeals letters
• Work closely with hospital leadership, medical staff, and hospital ICM leaders to support system CPIs and initiatives
• Attend and participate in Hospital UM committees at designated sites
• Complete training and continuing education as deemed necessary
• Attend and participate in educational presentations to medical staff, administration, leadership and peers
• Additional functions as deemed appropriate and warranted

Skills

Interpersonal skills

Regulatory knowledge

Medical license

Board certification

CMS guidance knowledge

Documentation integrity

EMR proficiency

Communication skills

Prioritization

Leadership style

Education

Doctorate of Medicine or Osteopathy

Accredited residency training

Tools

EMR systems

Job description

Sentara Healthcare Inc in Virginia Beach seeks a Physician Advisor to perform timely and compliant medical necessity reviews and assist with denials management within the centralized Utilization Review process for Sentara hospital facilities.

The role entails close collaboration with Clinical Revenue Cycle, UR, hospital leadership and medical staff, providing education to attending physicians on regulatory requirements and documentation standards to support hospital status and billing.