Job Description

Job Description

To serve as a liaison with providers, case managers, hospital leadership and payors on utilization management and revenue integrity. Provide education to ensure physician documentation appropriately supports the actual care provided.

Responsibilities and Scope of Work

Concurrent/Pro-Active:

  • Provide secondary reviews for appropriate patient status and level of care and discuss with the attending as appropriate.
  • Resolve concurrent patient status and level of care disputes with payors and physicians.
  • Provide education to physicians and case managers on denial and payor trends, Interqual and admission criteria, documentation, and CMS/other regulatory requirements and updates.

    Other:
  • Review payor denials and assist in the appeals process as necessary including attending ALJ hearings.
  • Review CDI queries for completeness and accuracy, consult with physicians to ensure accurate and timely responses.
  • Assist case management in assessing regulatory compliance with Code 44, 72 hour rule, Important Message from Medicare notifications, HINN and two midnight rule.
  • Assist case management in reviewing one day stays and provide feedback to physicians.
  • Support the hospitals by attending length of stay rounds/meetings, case management meetings and utilization management committee meetings, as available/requested.

Qualifications

  • Maintains a medical license from the state of Massachusetts.
  • A member of the American College of Physician Advisors
  • Previous utilization management, case management or peer review documentation experience in hospitals or health plans.
  • In clinical practice within the past five years.
Has the ability to travel among the Northeast hospitals on a regular basis.

Application Instructions

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