This physician leader oversees medical necessity, utilization review, and revenue integrity activities for hospitalized patients, with a focus on level-of-care decisions, length-of-stay review, denials, and compliance with payer and regulatory requirements. The role also provides education and case review support for clinicians, CDI, coding, and care management teams, while helping improve documentation, readmissions, and value-based care initiatives. The work is highly collaborative and includes committee leadership, peer-to-peer discussions with payers, and partnership with hospital leadership and data teams.
Key Responsibilities
- Provide leadership for revenue integrity functions, including CDI, coding, and utilization review.
- Review medical records for medical necessity, level of care, continued stay, and utilization oversight.
- Chair the Utilization Management Committee and support utilization governance.
- Educate physicians, UR staff, and stakeholders on coding, documentation, clinical criteria, and utilization practices.
- Conduct peer-to-peer discussions with payer medical directors when needed.
- Collaborate with CDI, coding, case management, and data teams to improve review processes and support DRG assignment.
- Support efforts to reduce avoidable readmissions, excessive cost of care, and inappropriate utilization.
- Participate in committees and leadership discussions related to quality, evidence-based care, contracts, and revenue strategy.
Required
- MD or DO with an unrestricted medical license in Wyoming, or ability to obtain one.
- At least 10 years of healthcare and/or patient care experience.
- At least 2 years of experience in healthcare business, revenue cycle, utilization management, coding, clinical documentation improvement, or regulatory value programs.
- Current American College of Physician Advisors (ACPA) membership.
- Ability to obtain ABQAURP certification or ACPA-C certification within 6 months of start date.
Preferred
- Certified Medical Director (CMD) credential.
- Experience in medical billing, coding, or abstracting.
- Internal Medicine background with Hospital Medicine experience.
- Experience with InterQual.
- Experience with MCG.