Part Time Optum Utilization Review Jobs in Connecticut

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POSITION SUMMARY

The Physician Advisor provides physician leadership and clinical expertise in utilization management, medical necessity, level-of-care determinations, clinical documentation, length-of-stay management, and denial prevention. The Physician Advisor serves as a liaison between the medical staff, Care Management, Utilization Management, Clinical Documentation Integrity, Revenue Cycle, Quality, and other hospital departments.

The Physician Advisor promotes the delivery of high-quality, medically appropriate, and cost-effective care while supporting compliance with applicable federal and state regulations, payer requirements, and hospital policies.

ESSENTIAL FUNCTIONS

• Provide physician-level review and guidance regarding medical necessity, patient status, level of care, and continued stay.
• Review complex cases to determine appropriateness of inpatient admission, observation, continued stay, and alternative levels of care.
• Collaborate with attending physicians, hospitalists, specialists, case managers, utilization review nurses, CDI specialists, coding, and other members of the care team.
• Identify opportunities to improve length of stay, resource utilization, patient flow, and appropriate discharge planning.
• Provide education and consultation to physicians regarding documentation requirements and medical necessity.
• Assist with prevention, management, and resolution of payer denials and downgrades.
• Participate in peer-to-peer discussions with payer medical directors as appropriate.
• Assist with appeals and retrospective denial reviews by providing clinical expertise and physician-to-physician communication.
• Support accurate clinical documentation to ensure the medical record appropriately reflects the patient’s clinical condition and severity of illness.
• Participate in Utilization Review Committee activities and other appropriate medical staff and hospital committees.
• Monitor utilization trends and identify opportunities for improvement.
• Collaborate with Revenue Cycle and other operational leaders to identify opportunities to improve reimbursement while maintaining appropriate clinical care.
• Serve as a physician resource for complex utilization, documentation, quality, and patient-status questions.
• Promote compliance with CMS, Medicare, Medicaid, commercial payer requirements, and applicable regulatory standards.
• Develop and maintain effective working relationships with medical staff and hospital leadership.
• Participate in quality improvement and performance improvement initiatives related to utilization, patient flow, documentation, and denials.
• Maintain current knowledge of regulatory requirements, payer policies, utilization management standards, and industry best practices.
• Perform other duties as assigned.

•  Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school.
• Current, unrestricted Connecticut medical license.
• Board certification or board eligibility in an appropriate medical specialty.
• Completion of an accredited residency program.
• Minimum of 5 years of clinical physician experience, preferably in an acute-care hospital setting.
• Demonstrated understanding of medical necessity, utilization management, patient status, length-of-stay management, and clinical documentation.
• Ability to effectively communicate and collaborate with physicians, clinical staff, hospital leadership, payers, and interdisciplinary teams.

PHYSICAL/WORK REQUIREMENTS

This position primarily involves clinical record review, meetings, physician consultation, computer-based work, and communication with internal and external stakeholders. The position may require occasional presence in clinical areas and participation in hospital meetings and committees.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.