Out of curiosity, I did a quick search on internet.... Found this job posting: it may give you a general idea of the responsibilities entailed. Although it does not answer your question of how to get started, I would just contact prospective employers and ask....
Career Opportunities
ABOUT HEALTHDATAINSIGHTS
HealthDataInsights, is the industry leader in healthcare claims integrity (fraud, waste, abuse, errors, overpayment identification and recoupment solutions). HealthDataInsights is headquartered in Las Vegas, Nevada with facilities in both California and Florida. The companys clients include government payors (Centers for Medicare and Medicaid Services), many of the nations largest health plans, and major employers. As Medicares exclusive Recovery Audit Contractor in Region D (17 states), as well as the vendor of choice for Americas largest commercial health plans, HDI reviews over $300 billion in claims paid per year. HDI is a subsidiary of HMS Holdings, Inc., a public company. HMS is the nations leader in cost containment solutions for government-funded, commercial, and private entities.
Utilization Review Physician
Utilization Review Physicians are responsible for independently auditing medical records and bills for accuracy and necessity. The primary focus of this position is to identify properly underpayments and overpayments. The UR Physician will review and certify the medical necessity of prospective, concurrent, and retrospective units of inpatient and outpatient services provided.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Provide clinical expertise and judgment in the accurate review of medical records submitted in support of claims identified as being at risk for improper payment
Review, summarize and provide testimony on medical record determinations
Perform independent medical record case review to validate medical necessity and level of care for correct billing
Review case-specific patient information concurrently for the medical necessity of hospital admissions using commercial review criteria and/or scripted guidelines
Demonstrate critical thinking, interpersonal oral and written communication skills to support review findings
Ensure consistent application of the utilization review process for all functional components
Provide guidance and education to the Health Care Management (HCM) Team regarding proper application of National and Local Coverage Determinations (NCDs, LCDs), Review Guidelines, CMS Internet only manual, etc.
Serve as a readily available source of medical information to the review team regarding particular claim reviews
Participate in special projects as needed and participate in team meetings
Develop proficiency in using Milliman Care Guidelines, InterQual® and CMS guidelines for medical necessity
Manage workload to ensure timely processing per state and federal mandates
Perform other duties as assigned
JOB REQUIREMENTS
Doctor of Medicine or a Doctor of Osteopathy from an accredited Medical School in the United States
Current licensure to practice medicine in the United States
Knowledge of coverage and reimbursement rules of the Medicaid and/or Medicare program
Sound clinical judgment
Proficiency in Microsoft Word and Excel programs
Working knowledge of HIPAA Privacy and Security Rules and CMS security requirements preferred
Familiarity with coding principles to include ICD-9, CPT, HCPCS, RUGS, and MS-DRG preferred
Two (2) years experience in Utilization Review, Case Management and Medical Record Review preferred
Ability to work well either alone or cooperatively and effectively with individuals and groups
JOB Location
Las Vegas, NV (must be willing to relocate immediately)
SALARY & BENEFITS
Competitive salary plus medical, dental, vision, flex savings, pre-paid legal, short-term and long-term disability, and life insurance benefits in addition to a 401k retirement plan, nine paid holidays and a paid time off (PTO) plan.
CONTACT
For immediate consideration, please submit your resume, salary & bonus history (mandatory in order to receive consideration for the position), and daytime contact information to
[email protected] marked Utilization Review Physician" in the Subject heading of the e-mail. Please note that we will be unable to respond to each resume received, but also note that your resume will be reviewed in a confidential manner. Thank you for your time and interest! HDI is an Equal Opportunity Employer. PRINCIPALS ONLY
