Physician Advisor

Overview

The Physician Advisor (PA) will act as a liaison between the medical staff, revenue cycle, physician leadership teams, and hospital administration teams ensuring that the system is optimized for regulatory compliance, medical necessity, and efficient utilization of health care services. The PA conducts clinical reviews on cases in accordance with the hospitals objectives for assuring quality patient care and effective clinical documentation.

Essential Functions

• The PA meets with care management and health care team members to discuss selected cases and make recommendations for care, 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 acts as consultant to and resource for providers regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources.
• The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations.
• Acts as second-level reviewer through the review of medical records of patients identified by care managers or as requested by the healthcare or administration teams.
• Assist with the patient status determination (level of care) and length of stay management.
• Assist with the denial management process.
• Review and make suggestions related to resource and service management.
• Assist staff with the clinical review of patients.
• Determine if professionally recognized standards of quality care are met.
• Optimization of the observation rates and observation length of stay.
• Provides feedback to providers regarding level of care, length of stay, and quality issues. Seeks additional clinical information from the providers. Recommends and requests additional, more complete, medical record documentation. Recommends next steps in coordination of care and evidence-based medicine indicators.
• Reviews cases that indicate a need for issuance of a hospital notice of non-coverage/Important Message from Medicare. Discusses the case with the attending physician and if additional clinical information is not available, discusses the process for issuance and appeal to the physician.
• Documents in patients’ electronic health record (HER) care reviews, decisions, and other pertinent information. Understands and uses Inter Qual and other appropriate criteria. Documents response to case management referrals. Supports Care Management in a data-driven approach.
• Notifies the care manager of any conflict of interest in reviewing a patient’s record. Assists with identifying a physician to review such record.
• Acts as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate. Facilitates, mentors, and educates other providers regarding payer requirements.
• Participates in review of long stay patients, in conjunction with the Care Management Leadership, Care Management Team and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care. Participates in patient rounds with the healthcare team as indicated.
• Identifies patients who are appropriate for transfer to lower levels of care such as skilled nursing facilities (SNF), palliative care, longterm care, assisted living, LTACH facilities, and hospice. Works with physicians to facilitate referrals as needed.
• Provides guidance to emergency department (ED) physicians and ED Care Management regarding status issues and alternatives to acute care when acute care is not warranted.
• Works with Care Management and an interdisciplinary team to ensure appropriate continuity of care and to reduce readmissions.
• Provides education to providers related to regulatory requirements, appropriate utilization, alternative levels of care, community resources, and end of life care. Works with physicians to facilitate referrals to the continuum of care.
• Assists physicians with end of life care, palliative care and hospice care consultations when appropriate.
• Provides education to physicians and other clinicians regarding providing the appropriate level of care.
• Identifies clinical quality, patient safety,…