Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.
- Make recommendations on level of care including initial level of care, secondary review and as requested by case management.
- Review for daily level of care recommendations on cases placed in Observation.
- Participate in the denials management process and be a leader in optimizing denial management.
- Perform peer to peer appeals and draft appeal letters for third party denials as appropriate.
- Apply the 2-midnight rule to Medicare reviews and maintain compliance with Medicare rules as it applies to level of care recommendations.
- Stay current on changes in payer rules including CMS rules as it pertains to utilization review.
- Recommend and request additional and more complete medical record documentation from providers to support placement status or medical necessity.
- Understand and use InterQual and/or other appropriate criteria.
- Apply medical expertise to assist with appropriate billing for services.
- Provide feedback to Contracting on payer denial patterns where appropriate.
- Facilitate, mentor and educate physicians regarding documentation and payer requirements.
- Facilitate, mentor and educate case management on the utilization review process.
- Chair and/or assist the Lead Physician Advisor in chairing the Utilization Committee.
- Doctor Osteopathic Medicine (Required).
- Medical Doctor (Required).
Education or Equivalent Experience
- Education Specialization: MD or DO Equivalent Experience.
- Minimum 5+ years clinical experience in a hospital setting.
- Solid foundation in the areas of utilization management and hospital operations.
- Possess and maintain an unrestricted medical license in the State of Pennsylvania.