Physician Advisor - Utilization/Denial Management in Ontario, CA at Prime Healthcare

Date Posted: 11/9/2019

Job Snapshot

Job Description


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.



•         Current MD License in the State of Practice

•         Five or more years Clinical Physician Experience

•         Two to Five Years Utilization Review, Denial Management, Case Management or related experience.

•         Knowledge of CMS Regulations

•         Must have expertise with Interqual and/or Milliman Disease Management Ideologies

•         2-4 years of current experience with reimbursement methodologies

•         Experience with peer to peer review of clinical denials.

•         Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement.

•         Experience working with varied EMRs including Meditech and EPIC



We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.  EEO is the Law: