Senior Physician Advisor (PA - Utilization Management)

We've made a lot of progress since opening the doors in 1942, but one thing has never changed - our commitment to serve, heal, lead, educate, and innovate.  We believe that every award earned, every record broken and every patient helped is because of the dedicated employees who fill our hallways. 

At Ochsner, whether you work with patients every day or support those who do, you are making a difference and that matters.  Come make a difference at Ochsner Health and discover your future today! 

The Physician Advisor (PA-Utilization Management) serves as the physician leader in matters relating to patient care. The PA will partner to reduce length of stay, ensure appropriate use of level of care determinations (inpatient, observation, outpatient, and other classifications as identified), support documentation and coding improvements and ensure organizational compliance in all areas. PAs facilitate communication across the patient care continuum (including the Interdisciplinary and Post-Acute teams, Payors, Administration and Revenue Cycle) to improve utilization management, sustain quality goals, and act as a consultant to physicians, administration, and case management to assure appropriate resource usage, document medical necessity, and comply with Federal and State regulations/quality initiatives. Reports to the System Medical Director of Utilization.

This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at Ochsner's discretion.

Training, Certification and Skills

• Member of (1) American College of Physician Advisors (ACPA) or (2) Board Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or (3) Physician Advisor Sub-Specialty Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or (4) commitment to apply for such certifications

• Demonstrated ability to build rapport with medical staff and hospital leadership.

• Comfortable having challenging conversations

• Strong computer skills and working knowledge of EMRs

• Demonstrated ability to deliver high quality, cost-effective, efficient patient care services

• Utilization Management experience (preferred)

• Familiarity with: Current medical literature, Healthcare reimbursement issues (e.g., medical necessity, levels of care, coding), MCG / InterQual screening criteria, Medicare / Medicaid compliance, medical staff structure, policies and procedures

• Physician Advisors will have access to the required reports and data to make decisions, and to all pertinent federal, state regulations, laws, and policies and facilitate dissemination of relevant information to hospital clinical staff as appropriate.

Essential Position Duties

Create and Sustain Partnerships

• Partner and collaborate with stakeholders in the support of appropriate management of patient care activities; Intercede on issues as needed to gain appropriate resolution (especially via direct with Provider communication; includes Case Managers, Coding, Revenue Cycle, Insurance Companies)

• Respond to requests for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management department in a timely fashion.

• Work with physicians on concurrent appeals (peer to peers)-discussions, appeals and denials

• Serve as an education resource to clinical and non-clinical personnel regarding medical necessity and regulations.  (to include administration, providers, and operations teams)

• Work side by side with case managers, giving direction and education on patient process flow and provide support to foster trust within medical staff   

Manage Patient Flow

• Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews

• Assist with length of stay management and utilization of resources

• Assist with the denial management process

• Review medical records of patients identified by case managers or as requested by stakeholders to perform quality and utilization oversight

• Provide regular feedback to physicians and all other stake holders regarding level of care, length of stay, and potential quality issues

• Recommend and request additional complete medical