340bemployed.org

The Physician Advisor is a physician serving the hospital through teaching, consulting, advising and educating the Care Management Department, Hospital, and Medical Staff on matters regarding physician practice patterns, over and under-utilization of resources, compliance, regulatory statutes, and collaborative relationships with payers. The Physician Advisor is considered a key member of a Care Management Departments success in industry best-practice models and is a key leader charged with meeting goals of cost and outcomes in the organization. The position requires medical expertise, clinical judgment, and experience to support improvement in the appropriateness and continuum of care alternatives to support patient-centric care.

Job Description Details:

• Directly communicates with care managers, attending physicians, and payers to resolve denial management issues timely.
• Utilize the hospitals clinical information system/electronic medical record, electronically scanned documentation, and current Care Management Information System to review cases and communicate decisions.
• Concurrently provide both verbal and written timely communication to third party payers and PA Medical Assistance for appeals.
• Consults with Department Chairman on cases where complex specific disease management is required
• Attends medical staff meetings and makes presentations to key constituencies to strengthen relationships and enhance communication between physicians and organizational leaders
• Reviews medical records when necessary and follows through with communication as to appropriateness of continued hospital stay and/or treatment plan, or documentation of care
• Presents data to the executive team, his peers and their affiliates
• Provides education to Medical Staff regarding length of stay concerns, Medicare changes, and internal and external related factors
• Maintains current knowledge of government regulations.
• Active member of the Utilization Management Committee.
• Review of referred cases for appropriate level of care utilizing CMS regulations and medical necessity.
• Review of medical record for Skilled Nursing Facility (SNF) qualifying stay.
• Review of one day stay Medicare cases for appropriate level of care, as per Reimbursement Integrity Team Lead.
• Documentation of level of care for referred determination in utilization management documentation system.
• Other duties as assigned.

Specialized Skills

• Working knowledge of DRG reimbursement system with associated LOS, documentation concepts,  & general coding guidelines
• Excellent negotiation, mediation and collaboration skills
• Excellent clinical review and critical analysis skills to conduct peer review audits
• Clear understanding of the guidelines for appropriate level of care designation as directed by the Centers for Medicaid and Medicare
• Excellent public speaking

Education

• PA License Physician (DO or MD), Board Certified Preferred
• Minimum of 3-5 years of clinical experience