Physician Advisor

Job Shift: Days

Job Type: Full Time

The Physician Advisor (PA) has responsibility for providing medical staff leadership to the Utilization Management Committee (UMC) and functions of the Case Management (CM) and Health Information Management (HIM)/Clinical Documentation Improvement Departments. The PA leads and promotes processes for patients to receive medically necessary and high quality care throughout the continuum of care. The PA also assists in reducing the financial risks associated with denials that are due to providing medically unnecessary or preventable services and extended length of stays.
Additionally, the Physician Advisor provides ongoing education and in-service instruction programs for the Hospital's medical staff (including residents and fellows in academic medical centers), nursing and ancillary personnel related to coding/clinical documentation improvement, compliance, and utilization management and quality issues. Further, the PA conducts and documents reviews and for cost and length of stay (LOS) outliers as referred by the non-physician reviewers. He/she conducts medical necessity reviews for cases not referred to an outsourced physician advisor company.

POSITION ACCOUNTABILITIES AND PERFORMANCE CRITERIA:

1. Serves as physician liaison and advisor to the Health Information Management Department/Clinical Documentation Improvement.
   • Shares expertise regarding improvements in documentation with both HIM and clinical staff.
   • Serves as lead educator with the medical staff for ICD-IO and clinical documentation improvement implementation.
2. Maintains communication with attending physicians relating to utilization management and clinical documentation to discuss criteria for admission and/or continued stay and/or clinical documentation.
3. Assists Hospital with physician communication in support of the process for Hospital Issued Notice of Non-coverage Letters ("HINN"), Medicare discharge appeals and Condition Code 44 responsibilities of the UM Committee.
4. Assists Hospital with issues related to appropriate pre-certification for elective admissions, direct admissions and procedures.
5. Discusses treatment plans with attending/specialty physicians when Case Management and/or Clinical Documentation Improvement staff request assistance related to the patient plan of care or documentation.
6. Reviews records and reports of patient care in Hospital, as well as cases referred by Hospital's Case Managers, HIM/CDI staff, Risk Managers and Directors of Clinical Quality Improvement to promote quality of patient care and identify utilization issues.
7. Serves as physician liaison with contracted secondary physician review company responsible for conducting and documenting reviews to determine medical necessity and level of care issues when patients do not meet InterQual@ criteria.
8. Serves as liaison between Hospital and Managed Care Medical Directors, representing the hospital concerns at regular joint operating meetings between the two organizations.
9. Supports or serves as chair of the Utilization Management Committee. Shares meaningful data to attendees and committee members. Utilizes data to direct and drive performance improvement. Present UM Plan to required committees and Governing Board.
10. Utilizes (Crimson) data to drive improved quality of care and reduce unnecessary variation:
    • Active Crimson user/Physician Champion
    • Reviews data regularly (at least monthly)
    • Identifies areas of opportunity and shares with physicians in multiple settings
    • Drives at least one focus improvement through UM Committee Action Plan.
11. In conjunction with Home Office Health Policy counsel, clarify with appropriate agencies (for example, State Medicaid agencies) regulations that pertain to utilization and denials. Provides feedback, when necessary, to McKesson regarding discrepancies between clinical standards of care and InterQual guidelines.
12. Supports and assists Case Management, as indicated, in real-time interventions when Hospital is notified of denials/down codes by appealing and reducing denials of payment through peer to peer communication with medical directors from various managed care plans. Communicates, as required, with payers or physicians to facilitate immediate reversal of adverse decisions or transfer to alternative levels of care. Assists with appeals process by sharing case notes, research or related documentation that will support appeal.
13. Supports and assists Clinical Documentation Improvement staff, as indicated, in real time intervention