Key Responsibilities:
1. Clinical Documentation Improvement (CDI):
- Collaborate with clinical teams and CDI staff to ensure accurate, complete, and compliant documentation of patient care.
- Conduct clinical reviews of medical records to verify that documentation accurately reflects the patient’s severity of illness, risk of mortality, and clinical outcomes.
- Educate healthcare providers on best practices for clinical documentation to support quality metrics and reimbursement.
- This role is also open to clinical time.
2. Utilization Management:
- Evaluate and approve medical necessity and level-of-care decisions, supporting appropriate use of hospital resources.
- Review admissions, continued stays, and discharge criteria for adherence to guidelines and policies.
- Provide guidance on case management and patient flow to improve efficiency and resource allocation.
3. Compliance and Regulatory Support:
- Ensure compliance with state, federal, and payer regulations, including Medicare and Medicaid guidelines.
- Collaborate with compliance and quality teams to identify areas of risk and implement corrective actions.
- Act as a resource for internal audits, denials management, and appeals related to medical necessity and documentation issues.
4. Physician Education and Communication:
- Offer education sessions for medical staff on topics such as CDI, coding, utilization review, and regulatory compliance.
- Serve as a liaison between physicians and administrative teams to foster understanding and alignment with policies and practices.
- Address physician concerns related to documentation, utilization management, and regulatory requirements.
5. Quality Improvement Initiatives:
- Participate in quality improvement and performance management programs aimed at enhancing patient outcomes.
- Assist in analyzing data to identify trends, areas for improvement, and opportunities to optimize care quality.
- Support initiatives related to value-based care and accountable care organizations (ACOs) by providing clinical insights.
6. Denial Management and Appeals Support:
- Review cases with potential for claim denials and support appeals as necessary, working closely with revenue cycle and appeals teams.
- Provide clinical expertise in managing denied claims to reduce financial risk and recover lost revenue.
Job Requirements
- 5 years of clinical experience
- Licensed physician in state of residence
- Board certified in a clinical specialty
- Certified by the American Board of Quality Assurance and Utilization Review Physicians, Inc (ABQUARP) - preferred
- Experienced in clinical practice with an understanding of utilization review
- Served on or chaired a Utilization Management Committee
- Demonstrated cost-efficient practice
- Clinical time, if desired, is flexible and negotiable.
Please send your CV to