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

Required Skills

Required Experience