Medical Director of Revenue Integrity

This role will be referred as Physician Advisor in this text. The Physician Advisor is a key member of the healthcare organizations leadership team and is charged with meeting the organizations goals and objectives for assuring the effective, efficient utilization of health care services. The Physician Advisor is a physician serving the hospital through teaching, consulting, and advising the care management and utilization review departments, healthcare data team and the hospital leadership.

The Physician Advisor shall develop expertise on matters regarding physician practice patterns, over and under-utilization of resources, medical necessity, levels of care, care progression, denial management, compliance with governmental and private payer regulations, appropriate physician coding and documentation requirements.

PRIMARY SCOPE OF SERVICE:

The Physician Advisor collaborates closely with the medical staff leadership, the entire medical staff, all areas of resource management, case management, and utilization management to develop and implement methods to optimize use of hospital services for all patients while also ensuring the quality of care provided. This includes working with hospital leadership in developing care management protocols with physicians and others to optimize length of hospital stay and efficient management of resources, ensuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities.

The Physician Advisor reports directly to the:

GENERAL REQUIREMENTS:

MINIMUM JOB SPECIFICATIONS:

• Hold and maintain or able to obtain an unrestricted medical license in the state of Wyoming.
• Possess or acquires a solid foundation, knowledge, and/or experience in the areas of utilization management, quality improvement, and patient safety.
• Familiarity with Inter Qual and MCG is preferred.
• Strong understanding of Medicare Two Midnight Rules
• Member of the American College of Physician Advisors (ACPA) .
• Board Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) or ACPA is required within 6 months of hire
• Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes.
• Prefer Internal Medicine specialist with a background in Hospital Medicine.
• Maintain active medical practice in their specialty (Can accommodate clinical time up to 0.15 FTE in the specialty (depending on availability).

ORGANIZATION EXPECTATIONS:

• Demonstrates behavior that supports the organizations mission.
• Adheres to all professional and performance expectations set forth within the medical staff bylaws, rules & regulations and complies with all (Hospital) established policies and procedures.
• Participate in ongoing training and education related to the Physician Advisor role and responsibilities including topics related to Utilization Management, Care Management and other related areas as requested.

LEADERSHIP:

• Provide functional leadership for the revenue integrity team Including CDI, Coding and Utilization Review.
• Responsible for oversight revenue integrity optimization.
• Lead value-based care initiatives for the organization.
• Chairs the Utilization Management Team.

UTITIZATION REVIEW SUPPORT:

• Review medical records of patients identified by case managers or as requested by the healthcare team including physicians to perform quality and utilization oversight.
• Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews.
• Conduct Peer to Peer discussion with Payor Medical Directors when requested.
• Provide regular feedback to physicians and all other stake holders regarding level of care, length of stay, and potential quality issues.
• Provide necessary clinical education to UR Case Managers regarding clinical criteria and appropriate use of screening tools.

CLINICAL DOCUMENTATION INGERITY and QUALITY REPORTING SUPPORT:

• For Medical Staff
  • Educates individual hospital staff physicians about ICD-10 and DRG coding…