Major Responsibilities:

Conducts clinical review as appropriate on cases referred by Care Management /Social Work/Utilization management staffand/or other health care professionals to ensure quality patient care and effective, efficient utilization of heath care services,appropriate level of care, and monitors the appropriate use of diagnostic and therapeutic modalities.Review cases, as appropriate, to identify potential for delay in care delivery that can impact transition to next lower level ofcare or extend LOS. Discuss case with UM/CM staff, site physician advisor, and/or attending physician, as needed.Reviews cases that indicate a need for issuance of hospital notice of non-coverage.Demonstrates knowledge of medical necessity criteria and ICD-10 guidelines. Maintains current knowledge of federal, stateand payer regulatory and contract requirements.Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, andalternative levels of care, community resources and end of life care.Collaborates with the medical staff and other health care professionals regarding the individual patient’s plan of care and care goals within proposed / expected timelines and clinical pathways.Assists with denial management process including denials prevention work and conducting peer to peer appeals.

Licensure, Registration, and/or Certification Required:

Medicine and Surgery, MD-DO license issued by the state in which the team member practices.

Education Required:

Doctorate Degree in Medicine.

Experience Required:

Typically requires 3 years of experience in clinical practice. Clinical Documentation Improvement and Utilization Management experience as a member of the UM oversight committee or past Physician Advisor experience preferred. Additional education in Quality, Utilization Management and documentation improvement / integrity through continuing medical education programs and self- study. Knowledge of national medical necessity criteria and ICD-10 coding guidelines.

Knowledge, Skills & Abilities Required:

Demonstrates knowledge of medical necessity criteriaMaintains current knowledge of federal, state and payer regulatory and contract requirementsStrong analytical and decision-making skillsMust be motivated and self-directed and possess qualities of leadership, interpersonal skills and the ability to communicateeffectivelyAbility to utilize computer based medical record and other electronic tools in conduction reviews, reviewing data, anddocumenting as appropriate to role.Basic computer skills typing 25-20 WPM preferred

Physical Requirements and Working Conditions:

Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.