Utilization Review Case Manager Jobs in Washington

Inova Fairfax Medical Campus is looking for a dedicated physician advisor to join the Utilization Review Advisor team. This role will be full-time Position.  

The Utilization Review Advisor (Advisor) position conducts timely and compliant medical necessity reviews and assists with denials management (facilitating and completing peer to peers, writing appeal letters) in support of the centralized system Utilization Review (UR) process for Inova hospital facilities. The Advisor serves an important role in ensuring compliant hospital status/billing for hospital patients. The Advisor interfaces directly with UR nurses and medical staff, providing concurrent communication and education regarding recommended changes in hospital status, pertinent regulatory requirements and guidance impacting the determination, as well as documentation integrity to support medical necessity of services being delivered.

Inova is consistently ranked a national healthcare leader in safety, quality and patient experience. We are also proud to be consistently recognized as a top employer in both the D.C. metro area and the nation. 

Featured Benefits:
      Committed to Team Member Health: offering medical, dental and vision coverage, and a robust team member wellness program.
       Retirement: Inova matches the first 5% of eligible contributions - starting on your first day.
         Tuition and Student Loan Assistance: offering up to $5,250 per year in education assistance and up to $10,000 for student loans.
         Mental Health Support: offering all Inova team members, their spouses/partners, and their children 25 mental health coaching or therapy sessions, per person, per year, at no cost.
          Work/Life Balance: offering paid time off, paid parental leave, flexible work schedules, and remote and hybrid career opportunities.

MD Physician Advisor Job Responsibilities:

• Perform timely and compliant medical necessity reviews, providing clear documentation of the pertinent details of the case to satisfy regulatory requirements and directly communicate any necessary changes 
• Recommend and request additional, more complete, medical record documentation
• Provide guidance to internal and external staff regarding status issues and alternatives to acute level of care when such care is not warranted
• Work closely with revenue cycle, managed care and to support system initiatives
• Attend and participate in Hospital UM committees at designated sites
• Provide education to internal and external staff related to regulatory requirements, appropriate utilization, and alternative levels of care
• Complete training and continuing education as deemed necessary
• Attend and participate in educational presentations to medical staff, administration, leadership and peers
• Additional functions as required

MD Physician Advisor Additional Requirements:

• Completion of an accredited residency training program
• Active and unrestricted state Virginia medical license
• Board certification in specialty required at time of hire
• 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   
• Familiarity with (Hospital) organization and case management operations    
• Excellent customer service and interpersonal skills
• Able to effectively present information, both formal and informal
• Superb written and verbal communications skills
• Ability to set and manage priorities
• Demonstrate flexibility, teamwork, and a collaborative leadership style
• Strong technical/computer

MD Physician Advisor Preferred Qualifications: 

We are Inova, Northern Virginia's leading nonprofit healthcare provider. Every day, our 26,000+ team members provide world-class healthcare to the communities we serve. Our people are the reason we're a national leader in healthcare safety, quality and patient experience. And from best-in-class facilities to professional development opportunities, we support them at every step. At Inova, we're constantly striving to be ever better - to shape a more compassionate future for healthcare. 

Inova Health System is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, pregnancy (including childbirth, pregnancy-related conditions and lactation), race, religion, sex, sexual orientation, veteran status, genetic information, or any other characteristics protected by law.