Physician Advisor-6027

Kingman Healthcare•Kingman, AZ

3d•Onsite

About The Position

All KHI employees are expected to perform their respective tasks and duties in such a way that supports KHI’s vision to be among the kindest, highest quality health systems in the country. This position involves performing timely and compliant medical necessity reviews, facilitating denials management, and collaborating with various hospital departments to support system initiatives and standardize best practices in utilization management and care progression. The role requires conducting medical record reviews, contacting attending physicians for clarification, and supporting case management staff with clinical decisions and patient care issues. Ensuring compliance with CMS regulations, payer requirements, and internal policies is crucial. The Physician Advisor will also assist with level of care and length of stay management, and review resource and service management.

Requirements

Completion of Medical Doctorate or Doctor of Osteopathy degree from an accredited medical school
Completion of an accredited residency training program
Board certification in specialty required at time of hire
Active and unrestricted state of Arizona medical license
Possess or acquire a working knowledge of CMS regulatory guidance and requirements as they pertain to UR and site of service decisions
Possess a working knowledge of clinical documentation integrity, hospital billing and coding processes and guidelines, case mix index, and DRG assignments
Familiarity with standard published leveling criteria such as MCG/InterQual and ability to apply professional judgment and patient-specific variables as may be necessary or justifiable

Nice To Haves

Minimum of 5 years of clinical experience, hospital clinical experience

Responsibilities

Perform timely and compliant medical necessity reviews, providing clear documentation of the pertinent details of the case to satisfy regulatory requirements and directly communicating any necessary.
Facilitate denials management through review of selected cases, conducting peer to peer discussion with third party payers as appropriate, and assisting with appeals letters.
Work closely with hospital leadership, medical staff, and hospital ICM leaders to support system CPIs and initiatives.
Partner with hospital leadership, physician advisors, and corporate administration to standardize best practices in utilization management and care progression.
Conducts medical record review in cases in question for medical necessity of admission, need for continued hospital stay, adequacy of discharge planning and quality care management.
Contacts attending physicians and/or consultants as needed to seek clarification or additional information, documentation requirements, discuss alternate level of care options, minimize denials, relieve bed capacity constraints and expedite care across the continuum.
Supports case management department staff as it relates to clinical decisions, escalation of patient care issues and management of long LOS patients.
Assists with level of care and length of stay management, assists with the denial management process, reviews and makes suggestions related to resource and service management, assists staff with the clinical review of patients, determines if professionally recognized standards of quality care are met.
Ensure compliance with CMS regulations, payer requirements, and internal policies related to utilization and medical necessity.
Performs other duties as assigned to support overall effectiveness of department and organization.