Physician Advisor

GENERAL

SUMMARY:

The Physician Advisor works closely with the Chief Medical Officer, medical staff, medical residents and fellows, and other leadership related to case/utilization management and revenue cycle.

Monitors and fosters optimization of all aspects of hospital resource management as it relates to utilization management. Works closely with care management (including discharge planning) and social services for all patients while ensuring the highest quality of care is provided. Collaborates with hospital leadership to ensure efficient management and delivery of resources, when requested. Works to ensure compliance with care management protocols to optimize length of hospital stay by eliminating avoidable days, effectively identifies elements of medical necessity for patient placement in appropriate levels of care and patient status, supports documentation integrity and compliance, and when requested, assists in monitoring the appropriate use of diagnostic and therapeutic modalities.

Is an expert in Centers for Medicare and Medicaid (CMS) rules and regulations related to patient status, clinician documentation, medical necessity, provision of services, and other topics related to case/utilization management.

Reports to Senior Director of Revenue Cycle.

** The Physician Advisor may not serve in this role while serving in another Bryan Health-related administrative role or while practicing clinically on any single calendar day.

PRINCIPAL

JOB FUNCTIONS:

1.
* Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2.
* Reviews medical records of patients referred by Care/Utilization Managers to perform quality, utilization, and patient status oversight.

3.
* Evaluates medical records of patients referred by Care/Utilization Managers and discusses with consulting and attending clinicians to determine medical necessity of hospital care and provision of services. Acts as the primary conduit between attending physicians and Care/Utilization Management staff ensuring Inpatient hospitalizations meet medical necessity criteria.

4.
* Investigates avoidable delay concerns referred by Care/Utilization Managers regarding patient outcomes during their hospital stay.

5.
* Chairs the Utilization Review Committee

6.
* Collaborates with Utilization and Care Management leadership to optimize case/utilization management workflows.

7.
* Performs Medicare short-stay reviews for potential Part B re-billing.

8.
* Serves as the hospital expert in determination of patient status for all payors.

9.
* Recommends and requests additional and more complete medical record documentation from clinicians to support medical necessity when needed.

10.
* Works with Care/Utilization Managers when needed regarding delivery of Medicare Advanced Beneficiary Notices (ABNs), Hospital-Issued Notices of Noncoverage (HINNs), or other patient notices regarding patient financial responsibility.

11.
* Prepares for and participates in payor medical director peer-to-peer discussions.

12.
* Develops and maintains effective working relationships with payer medical directors involved in peer-to-peer discussions.

13.
* When requested, participates in review of long stay/complex patients, in conjunction with the Care Management team, clinicians caring for the patient, and other members of the multidisciplinary team to establish optimal care and discharge planning.

14.
* Collaborates with other hospital leaders regarding trends related to quality, safety, and efficiency issues potentially leading to delivery of suboptimal care.

15.
* Supports the organization in quality improvement efforts requiring clinician input and/or involvement.

16.
* Participates in all organizational efforts to reduce hospital readmissions.

17.
* Educates clinical providers regarding payor and CMS requirements including inappropriate hospitalizations, inappropriate Inpatient status designations, and payor and CMS criteria involving medical record documentation, appropriate utilization of hospital services, and alternative levels of care.

18.
* Reports practice pattern trends and opportunities to the chief medical officer.

19.
* Works with inpatient clinical clinician leadership to ensure effective communication throughout the day.

20. Closely collaborates with the hospital Manager of Care/Utilization Management.

21. Holds routinely cadenced meetings with the hospital Care/Utilization Managers (at least quarterly) to review data and trends, identify opportunities for improvement or issues for escalation, and receive feedback.

22. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

23. Participates in meetings, committees and department projects as assigned.

24. Performs other related projects and duties as assigned.

REQUIRED

KNOWLEDGE, SKILLS AND ABILITIES:

1. Maintains current knowledge of state, federal, and payor regulatory and contract requirements along with familiarity in…