Lead Physician Advisor Full Time Days

Washington Hospital•Fremont, CA

20d•$100 - $250•Onsite

About The Position

The Lead Physician Advisor serves as a Washington Health leader by ensuring the appropriate use of medical resources, optimizing patient care, and maintaining compliance with regulatory standards. This position involves a comprehensive understanding of clinical practices, an ability to analyze complex medical data, and effectively communicating findings and recommendations. The Lead Physician Advisor evaluates patient medical records to confirm that hospital admissions, procedures, and treatments are necessary, and adhere to established guidelines. The Physician Advisor also collaborates closely with healthcare providers, including physicians, nurses, case managers, clinical documentation integrity (CDI), specialists, other CDI leadership and personnel to discuss cases and offer clinical insights that ensure the best patient outcomes while managing resources efficiently. Additionally, the Lead Physician Advisor’s involvement in interdisciplinary teams, including utilization review committees and quality improvement initiatives, underscores their commitment to enhancing patient care and resource utilization.

Requirements

Medical Doctorate (MD)
Current unrestricted physician license in the State of California.
Minimum of five (5) years of active clinical practice experience.
Active medical staff at Washington Health
Comprehensive knowledge of Medicare, Medicaid, commercial payer regulations, and utilization review requirements.
Ability to demonstrate expertise in medical necessity criteria, including InterQual and/or MCG guidelines.
Strong understanding of inpatient, observation and outpatient status determination processes.
Experience managing peer-to-peer reviews with payers and successfully overturning denials.
Knowledge of CMS Conditions of Participation, The Joint Commission standards, and state regulatory requirements.
Experience collaborating with Case Management, Clinical Documentation Integrity (CDI), Revenue Cycle, Quality and Medical Staff leadership.
Demonstrates ability to educate physicians regarding documentation requirements, admission status, length of stay management and regulatory compliance.
Strong analytical skills with the ability to interpret utilization, denials, length of stay, case mix index and throughput data.
Experience leading multidisciplinary teams and driving organizational performance improvement initiatives.
Excellent verbal and written communication skills, including presentation of complex clinical and regulatory concepts to physicians, executives, and governing bodies.
Ability to influence physician practice patterns through collaborative and evidence-based approaches.
Knowledge of value-based purchasing, quality metrics, readmissions reduction and population health initiatives.
Demonstrates ability to resolve conflicts and facilitate consensus among physicians and interdisciplinary teams.
Experience participating in medical staff committees, utilization management committees, and quality improvement programs.
Proficiency with electronic health records (EHRs), clinical documentation systems, and data analytics tools.
Ability to maintain confidentiality and exercise sound professional judgment.
Strong organizational skills with the ability to manage multiple priorities in a fast-paced healthcare environment.
Demonstrates expert knowledge of utilization management, medical necessity determination, clinical documentation integrity, case management, and compliance.
Applies sound clinical judgment and evidence-based decision-making when evaluating patient status, resource utilization, and medical necessity.
Maintains competency in InterQual, MCG, CMS regulations, payer requirements, and applicable accreditation standards.
Effectively prioritizes responsibilities and manages multiple concurrent projects, reviews, and organizational initiatives in a timely manner.
Demonstrates strong organizational skills with the ability to manage complex cases, competing priorities, and critical deadlines.
Utilizes data and analytics to identify trends, evaluate performance, and develop strategies for process improvement and operational excellence.
Interprets clinical, financial, and operational data to support utilization management, denial prevention, quality improvement, patient throughput initiatives, and CDI.
Demonstrates effective problem-solving skills and exercises independent judgment when addressing complex utilization and documentation issues.
Maintains accurate, complete, and timely documentation in accordance with organizational, regulatory, and payer requirements.
Safeguards confidential patient, physician, and organizational information in compliance with HIPAA and hospital policies.
Demonstrates proficiency with electronic health records (EHRs), utilization review platforms, clinical documentation systems, and data reporting tools.
Communicates clinical and regulatory information clearly and effectively to physicians, leadership, and interdisciplinary team members.
Promotes a culture of patient safety, quality care, and regulatory compliance through physician engagement and collaboration.
Identifies potential patient safety concerns, barriers to care, and quality issues and facilitates appropriate intervention and escalation.
Supports initiatives that improve care coordination, reduce preventable harm, enhance patient outcomes, and optimize resource utilization.
Demonstrates accountability, professionalism, and leadership while serving as a trusted advisor to physicians, staff, and organizational leadership.
Fosters a safe work environment by adhering to organizational safety policies and supporting employee health and safety practices.
Maintains competency through ongoing education, professional development, and participation in quality and performance improvement activities.

Nice To Haves

Physician Advisor certification
Minimum of three (3) years of experience in physician advisor, utilization management, Case Management, Clinical Documentation Integrity (CDI), or related leadership role

Responsibilities

Review patient medical records to assess the necessity and appropriateness of hospital admissions, continued stays, and clinical procedures, as well as handle second-level reviews and appeals for cases requiring additional clinical expertise or cases contested by insurers.
Serve as a clinical liaison between the utilization management and CDI teams, medical staff and hospital administration, facilitating clear and effective communication across departments.
Educate medical staff by offering direction on optimal resource utilization, ensuring compliance with clinical standards, and advocating for best practices to improve patient care and operational effectiveness.
Collaborate with case managers, social workers, CDI specialist and discharge planners to ensure coordinated care transitions and efficient discharge planning. Act as a resource for clinical staff, providing guidance on best practices and resolving complex clinical utilization an documentation issues.
Support Medicare requirements by ensuring compliance with CMS guidelines through active participation in the Utilization Management Committee.
Chairs weekly Complex Case meeting, including follow up action items
Conduct peer-to-peer coaching and education to resolve denial cases, ensuring accurate and efficient healthcare utilization and patient care.
Develop and conduct training programs for physicians, nurses, and other healthcare professionals on utilization management principles, clinical documentation improvement, and regulatory requirements. Provide ongoing education and support to ensure clinical staff are knowledgeable about and adhere to utilization management policies and clinical documentation integrity policies, procedures, and best practices.
Participate in and contribute to quality improvement projects and initiatives to enhance patient care, optimize resource utilization, and reduce healthcare costs. The Physician Advisor will monitor key performance indicators and develop action plans to address areas of concern. They will engage in continuous professional development and stay abreast of emerging trends and best practices in utilization management and healthcare quality improvement, and CDI.
Ensure that communication of vital organizational priorities reaches the front-line staff of each physician clinical group.
Foster a collaborative, positive, and supportive working and clinical environment.
Display evidence-based decision-making.
Exemplify exceptional leadership by maintaining a strong presence across the healthcare system, ensuring the highest standards of patient care and seamless and efficient team coordination.
Demonstrate commitment to inclusion, communication, collaboration, and teamwork.
Excel in collaborative and front-line decision-making, working closely with all members of the team to ensure strategic and effective healthcare operations.
Lead and participate in hospital-wide performance improvement initiatives designed to enhance quality, patient safety, regulatory compliance, and operational efficiency.
Utilize data analytics to identify opportunities for improvement related to medical necessity, length of stay, denials management, documentation quality, and resource utilization.
Collaborate with Case Management, Clinical Documentation Integrity (CDI), Quality, Revenue Cycle, and Medical Staff leadership to achieve organizational goals.
Monitor utilization management/CDI metrics and develop action plans to address identified performance gaps.
Participate in multidisciplinary committees and workgroups focused on quality outcomes, patient throughput, value-based care, and regulatory readiness.
Support organizational initiatives aimed at reducing avoidable denials, improving case mix index (CMI), reducing length of stay, and optimizing reimbursement.
Promote evidence-based practices and physician engagement to improve patient outcomes and organizational performance.
Provide recommendations to leadership regarding process improvements and best practices related to utilization management/CDI and physician advisor services.
Maintain current unrestricted physician licensure and board certification in accordance with applicable regulatory and medical staff requirements.
Maintain Physician Advisor certification or pursue advanced education and certification related to utilization management, clinical documentation integrity, quality, and healthcare compliance.
Complete all required hospital, medical staff, regulatory, and departmental education and training programs within established timeframes.
Remain current with evolving healthcare regulations, payer requirements, medical necessity criteria, and industry best practices.
Participate in continuing medical education (CME) activities to maintain clinical expertise and professional competency.
Attend relevant conferences, seminars, and professional association meetings to enhance knowledge and leadership effectiveness.
Actively seek opportunities for professional growth, leadership development, and continuous learning.
Serve as a resource and mentor to physicians, case managers, and interdisciplinary team members regarding utilization management and documentation practices.
Ensure compliance with all applicable federal, state, and local laws, regulations, and accreditation standards related to utilization management and physician advisor functions.
Maintain working knowledge of The Joint Commission standards, California Title 22 regulations, HIPAA requirements, CMS Conditions of Participation, and Office of Inspector General (OIG) guidance.
Adhere to all hospital policies, medical staff bylaws, rules, and regulations.
Support regulatory surveys, audits, and accreditation activities by providing physician advisor expertise and documentation as required.
Ensure patient confidentiality and privacy are maintained in accordance with HIPAA and organizational policies.
Promote appropriate documentation, medical necessity determination, and utilization review practices consistent with regulatory and payer requirements.
Identify and report compliance concerns, potential regulatory risks, and opportunities for corrective action.
Collaborate with Compliance, Quality, Medical Staff Services, and hospital leadership to maintain organizational readiness and regulatory compliance.
Demonstrate ethical conduct and professional integrity in all aspects of patient care, utilization management, and physician advisor activities.