Physician Utilization Review Advisor

Med-Metrix, LLC; Parsippany-Troy Hills (NJ); Remote; USD 120,000 - 165,000; Full time

Job summary

Med-Metrix, LLC is seeking a Physician Advisor to provide physician-to-physician reviews, clinical guidance, and education to promote evidence-based care and appropriate resource utilization.

You will support utilization review and case management teams with complex clinical decision-making, ensure documentation accuracy for ICD coding, severity of illness, and DRG assignment, and stay current with CMS and payer guidelines.

Qualifications

• MD or DO with an active, unrestricted medical license.
• US Board Certified in a recognized specialty.
• Minimum of 1 year of payor or provider-side utilization review or ABQUARP/ACPA certification.
• Basic technical skills with hospital EMRs required.
• Strong knowledge of utilization management and payer regulations.
• Familiarity with MCG/InterQual placement status criteria preferred.
• Member of the American College of Physician Advisors preferred.
• Excellent written and verbal communication skills.

Responsibilities

• Conduct physician-to-physician reviews for medical necessity, level of care and denial prevention/appeals.
• Support utilization review and case management teams with complex clinical decision-making.
• Communicate with Physician Advisory team, hospital physicians, care coordination and utilization management staff to encourage best practices for evidence-based care and documentation.
• Assist in improving documentation related to ICD coding, severity of illness, risk of mortality, and DRG assignment.
• Keep abreast of current CMS and MCG evidence-based guidelines to enable utilization management decisions.
• Maintain compliance with legal, regulatory and accreditation requirements and payor partner policies.
• Meet productivity and quality standards within established time requirements.
• Attend required training and meetings.
• Participate in peer review process as needed.
• Other duties as assigned.
• Use, protect and disclose patients’ PHI only in accordance with HIPAA standards.

Skills

Board Certification

Strong communication skills

Interpersonal skills

Problem solving

Urgency & results oriented

HIPAA awareness

Microsoft Office Suite

Education

MD/DO degree

Unrestricted medical license

Tools

EMR systems

Microsoft Office Suite

Job description

Med-Metrix, LLC is seeking a Physician Advisor to provide physician-to-physician reviews, clinical guidance, and education to promote evidence-based care and appropriate resource utilization.

You will support utilization review and case management teams with complex clinical decision-making, ensure documentation accuracy for ICD coding, severity of illness, and DRG assignment, and stay current with CMS and payer guidelines.