Physician Advisor Denials Analyst

Tampa General Hospital•Tampa, FL

About The Position

The Physician Advisor Denials Analyst (Physician Advisor Support) serves as a dedicated resource to Tampa General Hospital's Physician Advisors, facilitating the efficient management and resolution of clinical denials, specifically those related to Medical Necessity. This role is crucial in organizing, coordinating, analyzing and streamlining the Peer-to-Peer (P2P) review process and associated medical necessity denials workflows handled by Physician Advisors. Serves as a key liaison between the Physician Advisors, Utilization Management (UM) team and the broader Revenue Cycle/Denials Management team, ensuring seamless communication and workflow integration without duplicating efforts or encroaching upon the established responsibilities of the existing Revenue Cycle team members. Focuses exclusively on supporting the Physician Advisor function for Medical Necessity denials and does not manage other types of denials (e.g., coding, billing, administrative, technical). Responsible for performing job duties in accordance with mission, vision and values of Tampa General Hospital.

Requirements

Bachelor's Degree in Healthcare Administration, Nursing, HIM, or other related field.
Minimum of three (3) years of experience in a healthcare setting, within utilization management, revenue cycle, analytics, denials management or related experience.
Strong understanding of medical necessity, clinical validation standards and denial management processes.
Clinical judgement to determine medical necessity criteria (e.g., InterQual, MCG).
Expertise in ICD-10-CM/PCS, MS-DRG, APR-DRG and Medicare Inpatient Prospective Payment System (IPPS).
Proficiency in analyzing healthcare data and identifying denial trends.
Proficiency in using electronic health records (EHR) systems and standard office software (e.g., Microsoft Office Suite).
Experience analyzing data with Excel or Analytics software and formulating data-related presentations.
Exceptional organizational and time management skills with the ability to manage multiple tasks and deadlines effectively.
Strong communication (written and verbal) and interpersonal skills to interact professionally with physicians, clinical staff, payers and internal teams.
Detail-oriented with strong analytical and problem-solving abilities.
Ability to work independently and as part of a collaborative team.
Ability to communicate using medical terminology, with information used from clinical documentation and knowledge of the payer denial/appeals process.
Commitment to maintaining confidentiality and adhering to compliance regulations (e.g., HIPAA).

Responsibilities

Conducts thorough reviews of patient charts to assess the medical necessity of admissions, continued hospital stays, appropriate discharge planning and quality of care.
Analyzes denied claims to identify trends in reasons for denial, determine validity and develop strategies to overturn them.
Serves as primary point of contact for organizing and scheduling P2P reviews requested by payers for Medical Necessity denials.
Prepares necessary clinical documentation, case summaries and relevant information required by Physician Advisors for P2P calls and appeals
Tracks the status of all P2P reviews and Medical Necessity appeals managed by Physician Advisors, ensuring timely follow-up and resolution.
Maintains a centralized repository and tracking system for Physician Advisor denial activities, outcomes and associated documentation.
Monitors and reports on trends related to Medical Necessity denials and P2P outcomes, providing data to Physician Advisors and relevant leadership.
Collaborates with coding analysts to complete clinical validation (DRG-related) and coding appeals; authors appeal letters when warranted.
Serves as a liaison between medical staff, Case Management and payers, educating physicians on documentation importance and payer requirements to prevent future denials.
Engages in direct discussions with payer medical directors to advocate for the appropriateness of patient care and resolve medical necessity issues.
Provides input and recommendations for process improvements to reduce denials and enhance revenue cycle efficiency.
Coordinates effective communication and collaboration between Physician Advisors, attending physicians, UM staff, Revenue Cycle/Denials Management and payers regarding P2P scheduling and requirements.
Collaborates with the Revenue Cycle/Denials Management team by providing timely updates on P2P outcomes and Physician Advisor determinations on Medical Necessity.
Aligns roles and responsibilities across the team to ensure alignment of UM and Revenue Cycle teams.
Assists Physician Advisors in navigating internal systems and processes for denial review and appeal submission related to Medical Necessity.
Contributes to the development and refinement of workflows specifically related to the Physician Advisor's role in Medical Necessity denial management.
Ensures all activities and documentation comply with hospital policies, payer requirements and regulatory standards.