Care Progression Physician Advisor, Sutter Memorial Medical Center

We are so glad you are interested in joining Sutter Health!

Organization:

SHSO-Sutter Health System Office-Valley

Position Overview:

The Physician Advisor (PA) is a key member of the hospital's leadership team charged with meeting the organization's goals and objectives for ensuring the effective, efficient utilization of health care services. The PA will develop expertise on matters regarding physician practice patterns, over- and under-utilization of resources, medical necessity, documentation best practices, level of care progression, denial management and compliance with governmental regulations and conditions of participation and commercial insurance contracts. The PA is responsible for establishing, maintaining and strengthening the relationship with System Enterprise and the hospital to appropriately optimize the use of Sutter Health Internal Physician Advisor Services (IPAS). The physician Advisor will work closely with the medical staff, including house staff, and all utilization management (UM) personnel, Care Management (CM) personnel to develop and implement methods and strategies to optimize the use of hospital services. This includes care management processes that ensure patients are in the appropriate level of care with supporting documentation of regulatory compliance and accurate coding. The Physician Advisor (PA) conducts clinical reviews on cases referred by UM/CM staff and or other healthcare professionals to meet regulatory requirements in accordance with the hospital objectives for assuring quality patient care and effective, efficient utilization of health care services. The PA meets with care management, UM staff and health care team members and medical directors of third-party payers to discuss the needs of patient's and alternative levels of care. The PA acts as consultant to and resource for attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources. The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations. The PA will act as a liaison between the CDI (Clinical Documentation Improvement) professional, HIM (Health Information Management ) ,and the hospital's medical staff to facilitate accurate and complete documentation for coding and abstracting of clinical data, capture of severity, acuity and risk for mortality, in addition to Direct Report Groups (DRG) assignment.

Job Description:

These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).

JOB ACCOUNTABILITIES:

Support Central Care Management Operations:

• Provides PA support and clinical oversight to all programs managed through Care Management Operations: Clinical Denials and Appeals, Recovery Audit Contractor (RAC), Medicare Two Midnight Rule review, Concurrent denials review and processing, Peer to Peer discussion with payers, and Inpatient authorization clinical escalations.

• Works with Care Management Operations team to develop and implement care management standards, trends and analyze data to identify opportunities and design strategies and solutions to help improve care management processes.

• Actively participates and contributes to Care Management projects design and implementation and acts as a consultant and clinical expert for the department in all matters including Managed Care Contracting and payer disputes, Government and non-government audits.

Physician / Clinical team Education and Support:

• Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, alternative levels of care, community resources, and end of life care. Works with physicians to facilitate continuum of care.

• Provides education to physicians and other clinicians regarding inappropriate admissions and create action plans to address

• Identifies quality, safety, patient t satisfaction and efficiency issues leading to suboptimal care and take appropriate actions to resolve it.

• Promotes and educates healthcare team on a team approach to patient care. Promotes coordination, communication and collaboration among all team members.

• Supports the organization in quality improvement efforts requiring physician input and / or involvement.

Clinical Documentation Support:

• Educates individual hospital staff physicians about International Classification for Disease (ICD) coding guidelines, and clinical t