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.
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Hospitals and Health Care
Referrals increase your chances of interviewing at Brundage Group by 2x