Physician Advisor, Utilization & Denial Review

Optum; Greensburg (Westmoreland County); On-site; USD 150,000 - 190,000; Full time

Job summary

Optum is seeking a Physician Advisor to join the hospital-based team. The PA will help ensure appropriate utilization of health care services, develop expertise in medical necessity and documentation, and participate in peer-to-peer discussions with payors.

The role requires working on-site at the facility Monday through Friday, collaborating with medical staff, house staff, and leadership to optimize patient status and utilization management processes.

Qualifications

• MD or DO is required.
• Current, unrestricted medical license in Pennsylvania.
• 3+ years of experience in a hospital-based practice setting.

Responsibilities

• Conduct second level medical necessity/compliance status reviews for all payor types
• Meet with case management, utilization management, social work, and other healthcare team members to discuss selected cases and make recommendations regarding patient status through case reviews
• Interacting with medical staff to discuss medical necessity and concurrent denial cases
• Act as a consultant for the medical staff regarding their decisions for the appropriate medical necessity status of hospitalized patients and supporting documentation
• Participate in the claims denial process by conducting peer to peer discussions with commercial payor medical directors for cases that have been denied concurrently
• Serve as a physician member of the Utilization Review Committee, which may require non-clinical medical staff privileges application

Education

MD or DO

Job description

Optum is seeking a Physician Advisor to join the hospital-based team. The PA will help ensure appropriate utilization of health care services, develop expertise in medical necessity and documentation, and participate in peer-to-peer discussions with payors.

The role requires working on-site at the facility Monday through Friday, collaborating with medical staff, house staff, and leadership to optimize patient status and utilization management processes.