The Physician Advisor provides medical direction/ guidance to the Care Management Department in the areas of Utilization Management, Clinical Documentation Improvement, Charge Capture, transitions of care are related initiatives.  The Physician Advisor functions in a combined advisory, administrative and educational role and serves as a critical link between Care Management, the Medical Staff and the hospital for matters related to physician practice and behaviors as they affect quality and cost outcomes.

QUALIFICATIONS:

Education:

Graduate of a four year accredited U.S. Medical School or the equivalent.

Experience:

• Minimum five years’ experience managing patients with multi-system issues and comorbidities.
• Demonstrated knowledge of regulatory and compliance requirements.

Licensure/Certification:

• M.D. or D.O. Unrestricted License to practice Medicine in the applicable state(s).   
• American College of Quality Assurance and Utilization Review Physicians (ABQAURP CHCQM) Board Certification no later than 1 year from clinic start date.

Knowledge/Skills:

• Excellent verbal and written communication skills.
• Demonstrated competence in utilization management and clinical documentation improvement.
• Clinical knowledge and skills to act as a resource for Care Management department staff and as a liaison with physicians.
• Knowledge regarding regulatory and compliance requirements for documentation and billing. 

PREFERRED LEADER PROFILE:

Demonstrates the ability to act consistently with our Preferred Employee Profile, exemplify our core organizational values and exhibit the leadership competencies outlined in the Preferred Leader Profile.

Physician Leadership:

• Engage physicians in the following processes:
  • Clinical Documentation Improvement Program;
  • Medical necessity and levels of care;
  • InterQual Criteria;
  • LOS and avoidable day issues;
  • Avoidable readmissions;
  • Denials;
  • Payer contracts and role of the physician with the payer’s Medical Director;
• Effectively communicate with medical staff, addressing patient care dilemmas with goal of clarifying ambiguity, successfully managing change and maximizing patient outcomes;
• Integrate principles of quality improvement and evidence-based practice to improve overall patient care.

Transitions of Care:

• Facilitates communications between the hospital systems that support plan of care—especially the timely response of hospitalists, specialists, and other physicians;
• Provides decision support to physicians as requested for the development of medical plan of care and transition plan for complex patients with unclear goals of care and for issues related to utilization management;
• Provides consultation for patients being considered for Legacy funded discharge plan;
• Participates in patient care conferences and facilitates the development of patient-centered care plans where appropriate.

Utilization Management:

• General knowledge of medical necessity criteria for inpatient, observation and ambulatory status;
• Provides secondary review for determination of patient class when needed;
• Works within established processes when needed to intervene with payers, supports denial and appeal activities, admit and transfer decisions, and issuance of hospital-issued notices of non-coverage;
• Co-chairs the Utilization Management Committee and related outlier review meetings;
• Co-chairs the Readmission Committee meetings;
• Provides focused reviews on selected cases;
• Uses data to identify trends, root causes and strategies for improvement.
• Assists and contributes to the development and implementation of policies and procedures as needed.
• Remains current with all medical record requirements including dating and timing of orders and progress notes.

Clinical Documentation Improvement:

• Provides feedback and education to other members of the medical staff on opportunities for documentation improvement.
• Provides education and assistance to Clinical Documentation Improvement Specialists on questions of documentation completeness and accuracy.