Physician Advisor

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

Primary Responsibilities

• Conduct second level medical necessity/compliance status reviews for all payor types.
• Requirement to gain and sustain a working knowledge of the technical systems to perform case reviews.
• Meet with case management, utilization management, social work, and other healthcare team members to discuss selected cases and make recommendations regarding patient status through case reviews.
• Interacting with medical staff to discuss medical necessity and concurrent denial cases.
• Act as a consultant for the medical staff regarding their decisions for the appropriate medical necessity status of hospitalized patients and supporting documentation.
• Participate in the claims denial process by conducting peer to peer discussions with commercial payor medical directors for cases that have been denied concurrently.
• Coordinate with Optum/OPAS Subject Matter Expert(s) for questions regarding federal, state and payor and regulatory requirements.
• Serve as a physician member of the Utilization Review Committee, which may require non-clinical medical staff privileges application.
• Provide focused case by case education on utilization management topics (e.g., documentation) to the medical and UM staff.
• Develop and maintain a working knowledge and understanding of OPAS proprietary guidance regarding clinical diagnoses and disease states. Initial and ongoing training will be provided by OPAS.

Physician Advisor Will Not:

• Practice medicine during the hours scheduled, which includes:
  • Decision-making in a patient’s plan of care or discharge.
  • Write orders or prescriptions.
  • Provide on-call coverage.
  • Set hospital clinical or administrative policies.
  • Supervise house staff or hospital employees.
• Participate in any type of peer review (e.g., Quality, M&M).
• Participate in clinical research or clinical trials.
• Participate in the medical decision making of any hospital patient regarding appropriate treatment or course of medical care.
• Reproduce or recreate Optum’s proprietary guidance for distribution or use in any client educational modules.
• Execute any contracts on behalf of Optum.
• Post opinions related to medical necessity and patient status in any publicly disseminated publication/website without prior approval by appropriate Optum resources.

Required Qualifications

• MD or DO.
• Current, unrestricted Medical license in state of residence.
• Board certified/eligible.
• 3+ years of experience in a hospital-based practice setting.
• Demonstrated ability to build rapport with medical staff and hospital leadership.
• Ability to collaborate and partner with multiple constituents (administrative, clinical, leadership, etc.).
• Ability to be receptive to feedback and coaching.
• Proven solid communication and listening skills.
• Demonstrated organizational agility, assumes positive intent, discovers the power pathways and circuits, navigates the organizational maze to get things done.
• Proven solid computer skills and working knowledge of EMRs.

Preferred Qualifications   

• Physician Advisor and or Utilization Review experience.