Executive Director of Physician Advisor Services

AdventHealth•Orlando, FL

16h•$0 - $2,080,000•Onsite

About The Position

As the physician leader of the physician advisor program, the Executive Director (EDPA) manages, leads, educates, informs, and advises members of the Care Management, Revenue Cycle and applicable Medical Staff regarding specific regulatory updates, statistical trending and/or changes related to denial prevention measures for our contracted managed care payers. The EDPA is responsible for managing the day to day operations of the executive medical directors (physician advisors) in utilization management, assist Patient Financial Services (PFS) in claims management with denial prevention initiatives, and quality assurance related to inpatient care, outpatient care/observation stays and referral services. This position supports the SVP/CMO capacities at the facilities within the Central Florida Division – South Region (CFDSR) by ensuring the delivery of high-quality, efficient healthcare services throughout the continuum of care for the membership served by contracted medical group provider networks. The EDPA is an important contact for clinicians, external providers, contracted health insurance payers, and regulatory agencies. This role serves as 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. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. Demonstrates, through behavior, AdventHealth’s core values of Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork.

Requirements

Graduate from medical school and residency program
Ten (10) years recent clinical practice experience
Seven (7) years of leadership experience
Understanding of Hospital Care Management, including Utilization Management
Two years or greater experience as a Physician Advisor role
Current, valid State of Florida license as a physician
Board certified and eligible for membership on the Hospital medical staff

Nice To Haves

Master’s degree in Business or Healthcare Administration
Previous experience as a Chief Medical Officer (CMO) or Chief Quality Officer (CQO)
Certified Coding Specialist (CCS)

Responsibilities

Responsible for providing second level medical necessity reviews that do not meet first level screening criteria and properly evaluates inpatient utilization patterns within service areas to identify areas of improvement, developing specific strategies and criteria addressing areas of need.
Collaborates with Senior Medical Officers (and/or CMOs) with contracted managed care payers regarding utilization review management activities and maintain a positive and supportive relationship between the inpatient facilities, health plans and physicians (hospitalist groups and primary care providers), as well as interdepartmental liaison for ACO activities and program development.
Reviews and responds to Complaints & Indicators.
Works in close coordination with the processes of the Utilization Review Management staff for continual process improvement and reporting.
Reviews and makes recommendations on appealed provider claims and makes determinations for appeals & grievances from members.
Provides support, shares administrative call, and maintains collaborative relations with the other medical directors.
Participates with the Medical Directorate to review and develop medical guidelines and policies.
Advise and educate Care Managers regarding clinical issues.
Act as a physician champion for and attending physicians to arrive at most appropriate inpatient/outpatient utilization determinations.
Assists in other duties related to utilization review and quality improvement of the network as assigned by the CFO/SEO, SVP/CMO, Vice President Revenue Cycle and/or Executive Director, Middle Revenue Cycle
Reviews data and trends to identify opportunities for utilization improvement to positively influence practice patterns.
Conducts regular, ongoing meetings with Care Managers to ensure continuity and efficiency in the inpatient setting.
Performs other duties as assigned.
Develops clinical care pathways and utilization benchmarking for specialty groups within the CFDSR.
Manages specialty-specific quality screens and utilization outliers.
Collaborates and develops relationships with payers and the community health resources.
Actively contributes in efforts to monitor and reduce unnecessary length of stay.
Participates in review of long stay patients, in conjunction with the Director of Utilization Review Management or Executive Director, Middle Revenue Cycle to facilitate the use of the most appropriate level of care.
Provides education and serves as a resource to Medical Staff colleagues regarding best practices, Care Management structure and functions and uses of clinical guidelines.
Develops and facilitates productive internal/external relationships with all physicians and constituents of Care Management.
Acts as a liaison between contracted managed care/commercial payers related to clinical denials, Care
As a physician champion, the EDPA will consult with providers, particularly when difficult issues arise, and have critical conversations concerning resource utilization and medical necessity.
In addition to Care Management and Utilization Review, the EDPA may also work with the clinical documentation improvement team to capture the appropriate ICD-10 codes to ensure documentation reflects the clinical complexity for services rendered.
The EDPA will manage how peer to peers reviews are conducted with commercial payer medical director for cases that have been denied.
Educates, consults, and advises members of the Medical Staff on regulatory updates and changes related to Care Management.
Serves as chair of the Utilization Management (UM) Committee by ensuring committee is actively reviewing and acting upon trends identified through data.
Provides trend data of denials to assist in improving payer or care delivery behavior.
Aid in supporting Length of Stay (LOS) and quality goals.
Reviews concurrent payer denials and intervenes with attending and/or consulting physicians and managed care medical directors, as needed, for reconsideration and denial avoidance.
Provides input on developing plans for physician education to meet identified needs and provides information to members of the Medical Staff and clinical departments on Care Management guidelines and protocols.
Provides teaching and guidance to key associates and physicians regarding the impact of responsible stewardship of resources and attainment of important outcomes for each patient and family.
Responsible for managing the efficiency of inpatient care delivered in the organization and collaborates with all levels of managed care team, utilization review management, hospital executive team including the Chief Medical Officers, and leadership of medical and nursing staff.
Serves as a liaison between the AHS Managed Care Operations, Care Management, Revenue Cycle, Utilization Review departments, Medical Staff and the Chief Medical Officers for matters related to physician practice and behaviors as they affect cost, quality, documentation and patient outcomes.
Develops and fosters relationships with community post-acute care partners to ensure effective communication on patient’s continuum of care practices resulting in optimum patient outcomes