• Physician Advisor Clinical Appeals

    CommonSpirit Health (Englewood, CO)


    Job Summary and Responsibilities

     

    This is a remote position.

     

    This position represents 1 of 2 available opportunities.

     

    We are seeking a highly skilled individual to develop and submit clinical appeals, expertly crafting physician-aligned letters based on federal and state regulations, including CMS rules and the Two-Midnight Rule, while leveraging clinical criteria and prioritizing medical necessity to defend inpatient status. This role involves managing comprehensive, audit-ready case files with denial rationales and P2P documentation, ensuring successful appeals across all levels (1-5), including IRO and ALJ reviews, utilizing payer-specific tracking tools. The successful candidate will also collaborate cross-functionally with Utilization Management, CDI, coding, and compliance teams to reduce inpatient denials, identify payer trends, advocate for documentation integrity, strengthen audit readiness, and enhance clinician education.

    Essential Key Job Responsibilities

    + 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.

    + Understand the intricacies of ICD-9-CM, ICD-10-CM/PCS, MS-DRG, APR-DRG, and the Medicare Inpatient Prospective Payment System (IPPS) to make medical determinations on severity of illness, acuity, risk of mortality, and communicate with treating physicians in cooperation with the utilization team and health information personnel.

    + Serve as a liaison between the national care management team, medical staff, and medical executives to encourage physician cooperation and understanding of documentation importance

    + Assist in communications of internal physician advisor services in the hospital newsletters and other communication vehicles to further educate the medical staff.

    + Attends and participates in facility committee meetings, by invitation, as applicable.

    + Contacts Attending Physicians: Makes face-to-face and telephonic/electronic contacts and presentations to all medical staff physicians and potential physician groups introducing referral services, new products and present product offerings.

    + Conducts Peer to Peer discussions with payers as needed: Acts as a liaison and coordinator with operations for physicians. Attends applicable committee meetings, such as a Joint Operating Committee (JOC), as requested by Utilization Management or Managed Care: Works with the Care Management Director and staff to facilitate client profiles, clinical service utilization and support for revenue management activities.

    Job Requirements

    + MD or DO required

    + Minimum 3 years of experience as a Physician Advisor required

    + Minimum 5 years of experience in Clinical Practice required

    + Experience performing Peer to Peer Reviews required

    + Experience submitting written and verbal appeals required

    + Unrestricted license in field of practice in one or more states

    + In-depth knowledge of CMS regulations, including understanding of the 2-midnight rule.

    + Education in quality and utilization management through continuing medical education programs and self-study.

     

    Where You'll Work

     

    Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system.

    Pay Range

    $98.46 - $146.45 /hour

     

    We are an equal opportunity employer.