Adventist Health System Denials Management Physician Advisor in Altamonte Springs, Florida
Full Time, Monday-Friday
Adventist Health System Corporate Office
Be part of the Adventist Health System family.
Where you work matters. Working here is like being part of a family. Not just with those you serve, but also with your team members. It’s about making a difference, saving lives, and helping others live a fuller one. You’ll be joining a family of tens of thousands of team members who understand that what they do is bigger than healthcare. It is living out our mission to Extend the Healing Ministry of Christ and being there for someone every step of the way-body, mind, and spirit.
This is more than a career. It is a calling.
With hospitals and facilities in 9 states, you’ll have endless opportunities to take your talents, develop your skills, and grow as a professional in a place that truly cares about your success. If you are driven, compassionate, someone who always wants to go above and beyond because you care and believe what you do makes a difference – Adventist Health System is for you.
The Physician Advisor is responsible for writing and submitting clinical denial appeals, performing concurrent reviews and peer-to-peer discussions with payer representatives and educating clinical staff on process improvement opportunities to increase reimbursements and reduce clinical denials. This role utilizes clinical knowledge & experience, information science, and interpersonal skills to support and represent the optimal denials recovery and prevention processes identified with all medical, clinical and ancillary departments. This role researches and responds to denials in a timely fashion and identifies trends and responds to the trends by recommending changes in practice and/or documentation of the providers to promote a reduction in the denials trends. This role acts as a bridge between providers and other staff to improve clinical documentation, utilization review, and claim denials management. This position also serves as subject matter expert, providing clinical expertise and business direction in support of medical management programs, promoting the delivery of high quality, patient focused and cost effective medical care. Adheres to AHS Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies.
What you will be responsible for:
Responsible for writing and submitting appeals (multiple levels as needed) specifically around medical necessity, non-covered services, experimental care, authorizations, and inpatient/observation stay related denials.
Researches medical record, patient history and chart, payer contracts & policies to accurately represent patient care provided using medical & clinical justification in the appeal letter.
Analyzes denials data and trends to works with Managed Care contracting team and patient financial services to identify opportunities to address retrospective denials through the contracting process.
Reviews payer denials and intervenes with attending and/or consulting physicians and managed care medical directors, as needed, for reconsideration and denial avoidance. Makes determinations for appeals & grievances from team members.
Responsible for providing physician review of utilization, claims management, and quality assurance related to inpatient care, outpatient care/observation stays and referral services.
Provides input on developing plans for physician education to meet identified needs and provides information to members of the medical staff and clinical departments on Care Management guidelines and protocols.
Identifies opportunities for improving processes for collecting, analyzing and communicating performance improvement indicators pertaining to denials recovery and prevention.
Participates in denials management committees and provides updates on denials trends, issues and remediation plans.
Meet with clinical staff as necessary to create remediation plans for patient care that does not meet established care protocols, has insufficient documentation, or violates payer or regulatory policies.
Actively reviews and acts upon trends identified through data analysis. Provides trend data of denials to assist in improving payer or care delivery behavior.
Stays abreast of policies and regulations governing payers as well as AHS contractual language.
Strives towards meeting and exceeding productivity and quality expectations to align performance with assigned roles and responsibilities. Escalates concerns or difficulties in meeting performance expectations in a timely manner for management action.
Maintains a positive working relationship with internal staff and external providers, payer representatives, clinicians and patients and acts in a professional, courteous manner at all times.
Performs other duties as assigned by management.
What you will need:
Graduate from medical school and residency program
Ten years recent clinical practice experience
Seven years of leadership experience
Current, valid state license as a physician
Board certified and eligible for membership on the Hospital medical staff
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.