Full employer posting
Provides clinical expertise and guidance to Clinical Analysis and appeals team. Acts as the physician advisor for medical necessity appeals and for the Pennsylvania Medical assistance (PAMA) utilization reviews. Acts as a physician resource for the regulatory and revenue cycle denial and appeals processes for hospital activity, including utilization review for all PAMA cases, all UM denials and appeals.
Experience General Experience and strong working knowledge of the Interqual Criteria Set and hospital reimbursement systems Required General Experience in a role dealing with Second and Third level appeals processes including direct experience with being an expert witness Required General Experience in a managed care environment Required General Experience in an Administrative Leadership role Preferred Licenses PA Medical Physician License Required or PA Osteopathic Physician Required
Full-Time · Day Shift · 40 hours per week
About the role
Provides clinical expertise and guidance to Clinical Analysis and appeals team. Acts as the physician advisor for medical necessity appeals and for the Pennsylvania Medical assistance (PAMA) utilization reviews. Acts as a physician resource for the regulatory and revenue cycle denial and appeals processes for hospital activity, including utilization review for all PAMA cases, all UM denials and appeals.