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Physician Advisor, Medicaid Utilization Review (Acute Care)

Job brief

We are looking for a driven, tech savvy  Physician Advisor with a background in efficiency that can perform utilization reviews. 

Responsibilities

  • The Physician Advisor will be responsible for reviewing all denials of medical necessity, providing medical guidance to nursing staff, providing expert testimony at administrative hearings in support of the denial of services for all types of reviews, as necessary specifically with regards to Acute Care.
  • The Physician Advisor will lead the organization in appropriate resource utilization to meet regulatory requirements with regards to Medicaid Acute Care claims.  This Physician Advisor will collaborate with other clinical support staff to assure patients are managed in the most cost effective appropriate level of care and within regulatory requirements.  This Physician Advisor will make recommendations with regards to high utilizing providers to make appropriate practice pattern changes.

  • The Physician Advisor will conduct clinical reviews on cases referred by the Utilization review staff of nurses and/or other health care professionals to assure cases meet regulatory requirements and are in accordance with Medicaid’s objectives for assuring quality patient care and effective, efficient utilization of health care services.

  • The Physician Advisor meets with utilization review staff and health care team members to discuss selected cases and make recommendations for care, interacting with medical staff members and representatives of the Maryland Department of Health and Mental Hygiene. The Physician Advisor further acts as a resource for the medical staff regarding state utilization and quality regulations.

Required

  • Excellent communication skills and ability to collaborate well with large clinical and administrative team
  • Current active and unrestricted Maryland licensure as a Physician
  • Valid and unrestricted Federal/State registration to prescribe, dispense and administer controlled substances
  • Qualified as a "provider" under Medicare/Medicaid programs, doctoral degree in medicine (M.D. or D.O.), and board Certification in a primary care specialty
  • Minimum of 5 years in clinical practice

Desired

  • Previous experience in Utilization review and familiarity with its principles
  • Experience in managed care contracting and familiarity with Medicaid and managed care reimbursement policies
  • Prior management/ leadership or directorship roles in hospital, managed care and/or medical group practice.  
  • Strong technical background
  • Healthcare/medical informatics expertise.  
  • Ability to serve as health subject matter expert working with software teams to develop new products. 

Experience Required: Entry Level
Location: Columbia, MD
Type: Full Time

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