CommonSpirit Health
Overview
This is a remote position and represents 1 of 2 available opportunities. We are seeking a highly skilled individual to develop and submit clinical appeals, crafting physician-aligned letters based on federal and state regulations, including CMS rules and the Two-Midnight Rule. The role involves managing audit-ready case files with denial rationales and P2P documentation, ensuring successful appeals across all levels (1-5), including IRO and ALJ reviews, and utilizing payer-specific tracking tools. The successful candidate will collaborate cross-functionally with Utilization Management, CDI, coding, and compliance teams to reduce inpatient denials, identify payer trends, advocate for documentation integrity, strengthen audit readiness, and enhance clinician education.
Essential Key Job Responsibilities
Conduct medical record review to determine medical necessity of inpatient admission, need for continued hospital stay, adequacy of discharge planning and quality care management.
Understand ICD-9-CM, ICD-10-CM/PCS, MS-DRG, APR-DRG, and the Medicare Inpatient Prospective Payment System (IPPS) to make medical determinations on severity of illness, acuity, and risk of mortality; communicate with treating physicians in cooperation with the utilization team and health information personnel.
Serve as a liaison between the national care management team, medical staff, and medical executives to encourage physician cooperation and understanding of documentation importance.
Assist in communicating internal physician advisor services in hospital newsletters and other communication vehicles to educate the medical staff.
Attend and participate in facility committee meetings, by invitation, as applicable.
Contact Attending Physicians: make face-to-face and telephonic/electronic contacts and presentations to medical staff physicians and potential physician groups introducing referral services, new products, and present product offerings.
Conduct Peer-to-Peer discussions with payers as needed; act as liaison and coordinator with operations for physicians; attend applicable committee meetings (e.g., Joint Operating Committee) as requested by Utilization Management or Managed Care; work with Care Management Director and staff to facilitate client profiles, clinical service utilization, and support revenue management activities.
Job Requirements
MD or DO required
Minimum 3 years of experience as a Physician Advisor required
Minimum 5 years of experience in Clinical Practice required
Experience performing Peer to Peer Reviews required
Experience submitting written and verbal appeals required
Unrestricted license in field of practice in one or more states
In-depth knowledge of CMS regulations, including understanding of the 2-midnight rule
Education in quality and utilization management through continuing medical education programs and self-study
Where You’ll Work CommonSpirit Health is a national nonprofit Catholic health system focused on building a healthier future through integrated health services. We deliver care across clinics, care sites, and hospital-based locations with a diverse team of healthcare professionals.
Compensation Pay Range: $98.46 - $146.45 / hour
Note: This posting includes only the necessary job information. Other sections and postings shown in the original description that are not relevant to this role have been removed to improve clarity and focus.
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This is a remote position and represents 1 of 2 available opportunities. We are seeking a highly skilled individual to develop and submit clinical appeals, crafting physician-aligned letters based on federal and state regulations, including CMS rules and the Two-Midnight Rule. The role involves managing audit-ready case files with denial rationales and P2P documentation, ensuring successful appeals across all levels (1-5), including IRO and ALJ reviews, and utilizing payer-specific tracking tools. The successful candidate will collaborate cross-functionally with Utilization Management, CDI, coding, and compliance teams to reduce inpatient denials, identify payer trends, advocate for documentation integrity, strengthen audit readiness, and enhance clinician education.
Essential Key Job Responsibilities
Conduct medical record review to determine medical necessity of inpatient admission, need for continued hospital stay, adequacy of discharge planning and quality care management.
Understand ICD-9-CM, ICD-10-CM/PCS, MS-DRG, APR-DRG, and the Medicare Inpatient Prospective Payment System (IPPS) to make medical determinations on severity of illness, acuity, and risk of mortality; communicate with treating physicians in cooperation with the utilization team and health information personnel.
Serve as a liaison between the national care management team, medical staff, and medical executives to encourage physician cooperation and understanding of documentation importance.
Assist in communicating internal physician advisor services in hospital newsletters and other communication vehicles to educate the medical staff.
Attend and participate in facility committee meetings, by invitation, as applicable.
Contact Attending Physicians: make face-to-face and telephonic/electronic contacts and presentations to medical staff physicians and potential physician groups introducing referral services, new products, and present product offerings.
Conduct Peer-to-Peer discussions with payers as needed; act as liaison and coordinator with operations for physicians; attend applicable committee meetings (e.g., Joint Operating Committee) as requested by Utilization Management or Managed Care; work with Care Management Director and staff to facilitate client profiles, clinical service utilization, and support revenue management activities.
Job Requirements
MD or DO required
Minimum 3 years of experience as a Physician Advisor required
Minimum 5 years of experience in Clinical Practice required
Experience performing Peer to Peer Reviews required
Experience submitting written and verbal appeals required
Unrestricted license in field of practice in one or more states
In-depth knowledge of CMS regulations, including understanding of the 2-midnight rule
Education in quality and utilization management through continuing medical education programs and self-study
Where You’ll Work CommonSpirit Health is a national nonprofit Catholic health system focused on building a healthier future through integrated health services. We deliver care across clinics, care sites, and hospital-based locations with a diverse team of healthcare professionals.
Compensation Pay Range: $98.46 - $146.45 / hour
Note: This posting includes only the necessary job information. Other sections and postings shown in the original description that are not relevant to this role have been removed to improve clarity and focus.
#J-18808-Ljbffr