Anesthesiology Physician

The Utilization Management Physician Advisor II (PA) conducts clinical case reviews referred by case management staff and/or other health care professionals to meet regulatory requirements and in accordance with the hospital's objectives for assuring quality patient care and effective and efficient utilization of health care services. This individual meets with case management and health care team members to discuss selected cases and make recommendations for care as well as interacting with medical staff members and medical directors of third-party payers to discuss the needs of patients and alternative levels of care. The PA performs denials management and prevention in accordance with the organization's goals and expectations. This individual reviews cases for clinical validation, performs peer-to-peer discussions and participates in appeal letter writing. The PA acts as a consultant to, and resource for, attending physicians regarding their decisions relative to appropriateness of hospitalization, clinical documentation, continued inpatient stay, and use of healthcare resources. The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations. The PA helps facilitate training for physicians. The PA must demonstrate interpersonal and communication skills and must be clear, concise and consistent in the message to all constituents.

• Conducts medical record review in appropriate cases for medical necessity of inpatient admission, need for continued hospital stay, adequacy of discharge planning and quality care management.
• Understands the intricacies of ICD-9-CM, ICD-10-CM/PCS, MS-DRG, APR-DRG, and the Medicare Inpatient Prospective