Through primary support of UM, the Physician Advisor is responsible for providing clinical review of utilization, claims management, and quality assurance related to inpatient care, outpatient care/observation stays and referral services. The Physician Advisor is an important contact for clinicians, external providers, contracted health insurance payers, and regulatory agencies. This individual also serves as the subject matter expert, providing clinical expertise and business direction in support of medical management programs, promoting the delivery of high quality, patient focused and cost-effective medical care.
The Physician Advisor provides primary support for Utilization Management (UM) and secondary support for Care Management (CM) departments and serves as a liaison between UM and CM teams and liaison for payer escalations. The Physician Advisor is responsible for educating, informing, and advising members of the UM, CM, Managed Care and Revenue Cycle departments and applicable medical staff, as well as collaborating with other disciplines to assist in the improvement of clinical documentation, patient safety, and quality outcomes.
- Performs peer-to-peer discussions with payer Medical Directors and/or discusses cases with payer representatives to facilitate authorization determinations or claim resolution and build payer relationships
- Responsible for reviewing and authorizing inpatient (IP) days – performs secondary review escalations
- Maintains a positive and supportive relationship between the inpatient facilities, payers, and physicians (hospitalist groups and primary care providers), and acts as the interdepartmental liaison for ACO activities and program development
- Assists in formulation of reasonable clinical arguments to address any questions regarding medical necessity and/or level of care
- Coordinates and supports both concurrent (Utilization Management) and retrospective (CVBO) clinical denial management by reviewing and making recommendations on appealed provider claims and makes determinations for appeals and grievances from patients; assists in drafting and submitting clinical denial appeals, as needed
- Develops Medical Director relationships with payers to have open communication and consistently meets with these individuals to have mutually beneficial conversations to improve denials, decrease days in A/R and increase clean claims rate
- Provides clinical support/validation for both Utilization Management and Care Management teams
- Reviews denials data and trends and works with Managed Care contracting team and patient financial services to identify opportunities to address retrospective denials through the contracting process
- Serves as a participant of the Utilization Management (UM) Committee in person or virtually and shares observations, information and trends identified through data and case reviews
- Collaborates with Clinical Documentation Integrity leadership and meets at least quarterly to assist in the identification of clinical documentation improvement opportunities
- Provides education and serves as a resource to Medical Staff colleagues regarding best practices, Utilization Management and Care Management structures, functions, and use of clinical guidelines
- Provides guidance to clinical questions from Utilization Management staff involved in authorizations, concurrent review, and denials
- Assists with interpretation of specific application of medical necessity criteria
- Evaluates IP utilization patterns – Overutilization of specific resources/testing relating to a specific service area
- Collaborates with Corporate Chief Medical Officer
sand acts as a liaison between contracted Managed Care/Commercial payers related to managed care denials, Care Management, and the Hospital’s Medical Staff
- Works in close coordination with the processes of the Utilization Management staff for continual process improvement and reporting
- Supports long length of stay meetings/complex case review to effectively manage length of stay. Generates clinically sound alternative ideas and approaches to complex and/or long stay patients
- Assists in other duties related to utilization management, clinical documentation and quality improvement of the network as assigned by the Sr. Vice President of Clinical Operations
- Supports compliance with all State and Federal regulations
- Participates in ongoing CME opportunities related to Utilization Review and Discharge planning
- Other duties as assigned
REQUIRED KNOWLEDGE & SKILLS
- Knowledge and understanding of CMS, and other government payers, regulatory requirements regarding Utilization Review and Discharge planning.
- Able to foster strong positive relationships with payor medical directors
- Strong organization skills with attention to detail
- Excellent analytical and problem-solving skills
- Effective oral and written communication skills, with the ability to articulate complex information in understandable terms to all levels of staff
- Understanding of Microsoft Office Products and other appropriate software platforms
- Ability to work in a matrix-management environment to achieve organizational goals
- Ability to translate ethical and legal requirements into practical and sustainable policies, balancing the needs of the business and the interest of patients and member physicians alike
- Demonstrated ability to provide expert medical advice
- Successful history as a practicing physician
- Demonstrated ability to build and sustain relationships in the medical community and a corporate environment
- Payer experience in operations
- Experience in a physician group model
- Education: Graduate of an accredited Medical School required
- Experience: Minimum of 5 years of experience in hospital medicine in an acute care setting. Prior experience with third party payor preferred.
- Certification/Licensure: Active, unrestricted medical license (MD or DO) required.
- Software/Hardware: Microsoft Office suite and other appropriate software platforms required. Meditech experience as well as knowledge of InterQual©, Milliman or other commercial medical necessity products preferred.