Physician Advisor

Description

The Physician Advisor (PA) will drive quality performance across the organization by communicating with hospital physicians, utilization management, case management, CDI, the denials team, and quality staff. The PA conducts case reviews to ensure compliance, appropriate and accurate clinical documentation, and appropriate utilization of health care services. The PA will meet with hospital personnel and medical staff when needed to provide education and expertise. The PA acts as a consultant and resource for attending physicians regarding appropriate status, utilization of resources, need for continued hospitalization, compliance concerns and tracking and reporting of quality and complications. The PA will also interact with medical directors of third-party payers to discuss the medical necessity, utilization of resources and appropriate level of care.

Requirements

GENERAL SUMMARY:

The Physician Advisor (PA) will drive quality performance across the organization by communicating with hospital physicians, utilization management, case management, CDI, the denials team, and quality staff. The PA conducts case reviews to ensure compliance, appropriate and accurate clinical documentation, and appropriate utilization of health care services. The PA will meet with hospital personnel and medical staff when needed to provide education and expertise. The PA acts as a consultant and resource for attending physicians regarding appropriate status, utilization of resources, need for continued hospitalization, compliance concerns and tracking and reporting of quality and complications. The PA will also interact with medical directors of third-party payers to discuss the medical necessity, utilization of resources and appropriate level of care.

Duties And Responsibilities

Utilization Management Functions

• Reviews medical records of patients identified by the UM team or as requested by the healthcare team
• Perform status determinations including 2nd level reviews and continued stay reviews for traditional Medicare patients and all other payors
• Review Code 44 cases
• Assist with length of stay management
• Participate in multidisciplinary rounds and streamlined status rounds as needed
• Work with case management and the interdisciplinary team to ensure appropriate continuity of care and reduce readmissions
• Communicate with the medical staff through secure email, secure texting applications, phone calls and face to face interactions to relay important information and provide education
• Act as a liaison between Utilization Management/Case Management and providers to collaborate on appropriate plans of care
• Review and suggest improvements related to resource allocation
• Optimize coordination of care processes
• Provide guidance to ED Physicians and the UM/CM team regarding alternatives to acute care
  
  

CDI Functions

• Review documentation for clinical validity of diagnoses
• Support query response and query construction
• Educate physicians on documentation best practices
• Provide feedback to clinical providers
• Assist with pre-bill DRG
  
  

Quality Functions

• Review documentation to support quality metrics
• Educate providers on how quality is tracked and common pitfalls
• Review PSIs for appropriate assignment of complications
  
  

Denials Management Functions

• Review denials and author appeal letters as needed
• Perform peer to peers with payors
• Act as a liaison with payors to facilitate approvals and prevent denials or carved out days when appropriate
  
  

Other duties as assigned.

KNOWLEDGE, SKILLS, AND ABILITIES: Abilities may be accessed through written, verbal, and other evaluation methods.

• Expertise in Utilization Management preferred
• Strong interpersonal skills
• Excellent written and verbal communication skills
• Ability to work independently
• Ability to build relationships with key hospital team members
  
  

WORK EXPERIENCE, EDUCATION AND CERTIFICATIONS: List preferred/required work experience, education, and certifications.

MD or DO

Current, unrestricted medical license in state of residence

Demonstrated ability to build rapport with medical staff and hospital leadership

Strong computer skills and working knowledge of EMRs

Prior Physician Advisor experience or at least 3 years of clinical experience in a hospital-based setting

Preferred Qualifications

• Board Certified / Eligible
• CCDS or CDIP
• CCS
• CHCQM certification (ABQAURP)
  
  

Working Conditions And Physical Requirements

Conditions typically associated with an office environment. While performing the essential duties and

responsibilities, the employee is regularly required to talk or hear. May be frequently required to sit, stand or

walk. Moderate to prolonged reading, typing, and computer work. Ability to perform tasks involving physical

activity that may include lifting 25 pounds. Subject to exposure to all environmental hazards associated with

healthcare and office work.