Physician Advisor

JOB SUMMARY:

The Physician Advisor  conducts clinical case reviews referred by case management staff and/or other health care professionals to meet regulatory requirements and in accordance with the hospital’s objectives for assuring quality patient care and effective and efficient utilization of health care services. This individual meets with case management and health care team members to discuss selected cases and make recommendations for care as well as interacting with medical staff members and medical directors of third-party payers to discuss the needs of patients and alternative levels of care. The PA performs denials management and prevention in accordance with the organization’s goals and expectations. This individual reviews cases for clinical validation, performs peer-to-peer discussions and participates in appeal letter writing. The PA acts as a consultant to, and resource for, attending physicians regarding their decisions relative to appropriateness of hospitalization, clinical documentation, continued inpatient stay, and use of healthcare resources. The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations. The PA helps facilitate training for physicians. The PA must demonstrate interpersonal and communication skills and must be clear, concise and consistent in the message to all constituents. Exhibits the F.I.R.S.T. values (Friendliness, Innovation, Respect, Service and Trust).

ESSENTIAL FUNCTIONS, DUTIES AND RESPONSIBILITIES:

• Utilization Review Committee

1. Co-Lead the Utilization Review Committee with Facility representatives. 
2. At each meeting, report on findings of pertinent reviews completed by Provider and activities since the previous meeting. Other metrics as identified by the UR Committee. 
3. Report Utilization Review Committee findings to MEC
4. Work within the parameters of the Utilization Review Committee as defined by Medicare Conditions of Participation (42 CFR 482.30) and the UR Plan. 

• Concurrent Admission Review Includes, but shall not limited to: 

1. Review of medical records to determine admission status appropriateness using medical judgment when the documentation in the record does not support the ordered status as determined by MCG or other evidence based criteria 
2. Provide support and guidance regarding the appeals process to ensure both contractual and federal rule compliance. 
3. Uses medical judgment and evidence based practice research to determine appropriateness of status in collaboration with the treating physician. 
4. Consultation with the attending physician for documentation and additional clinical information, when needed. 
5. Provide education to the attending provider when documentation is not sufficient to support the status ordered. 
6. Reviews medical records and documents decisions within 3 hours of referral. 
7. Documents decision in designated area as directed by Facility. 

• Continued Stay Review Includes, but shall not be limited to: 

1. Review of medical records for continued stay appropriateness and/or resource utilization when the documentation in the record does not support the need for continued stay and/or resource utilization is high. 
2. Looks for technical elements required by payor and justification of extended stay and/or resource usage. 
3. Utilizes medical judgment and evidence based practice research to determine appropriateness of continued stay and resource utilization in collaboration with the treating physician. 
4. Consultations with the attending physician for documentation and/or additional clinical information, when needed. 
5. Review of medical records within 3 hours of referral 

• Concurrent Admission Denials Includes, but shall not be limited to:

1. Review of medical records when a payor disagrees with the status ordered by the provider while the patient is still in-house or prior to claim submission. 
2. Looks for technical elements required by payor 
3. Utilizes medical judgment and evidence based practice research to determine appropriateness of denial 
4. Works collaboratively with attending provider to craft justification for appeal of level of care, length of stay, and/or any other denial rationale 
5. Provide education to providers regarding missing elements that drove decision to not appeal specific claims. 
6. Performs Peer to Peer discussions within scheduled timeframe for inpatient medical necessity denials and a