Conducts clinical review as appropriate on cases referred by Utilization management staff and/or other health care professionals to ensure quality patient care and effective, efficient utilization of heath care services, appropriate level of care, and monitors the appropriate use of diagnostic and therapeutic modalities.

Review cases, as appropriate, to identify potential for delay in care delivery that can impact transition to next lower level of care or extend LOS. Discuss case with UM/CM staff, site physician advisor, and/or attending physician, as needed.

Reviews cases that indicate a need for issuance of hospital notice of non-coverage.

Demonstrates knowledge of medical necessity criteria and ICD-10 guidelines. Maintains current knowledge of federal, state and payer regulatory and contract requirements.

Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, and alternative levels of care, community resources and end of life care.

Collaborates with the medical staff and other health care professionals regarding the individual patient's plan of care and care goals within proposed / expected timelines and clinical pathways.

Assists with denial management process including denials prevention work and conducting peer to peer appeals.

Licensure, Registration and/or Certification Required:

Medicine and Surgery, MD-DO license issued by the state in which the team member practices.

Education Required:

Doctorate Degree in Medicine.

Experience Required:

Typically requires 3 years of experience in clinical practice. Clinical Documentation Improvement and Utilization Management experience as a member of the UM oversight committee or past Physician Advisor experience preferred. Additional education in Quality, Utilization Management and documentation improvement / integrity through continuing medical education programs and self- study. Knowledge of national medical necessity criteria and ICD-10 coding guidelines.

Knowledge, Skills & Abilities Required:

Demonstrates knowledge of medical necessity criteria