UM PA Lead

Tufts Medicine

2d•$135 - $165•Onsite

About The Position

The Physician Advisor, Lead is a critical role that ensures physician support for high quality, compliant and efficient workflows related to utilization management. As a representative of Tufts Medicine and CMO (s), the role provides clinical direction and leadership to the organization, increasing the ability to produce optimal patient outcomes; ensuring quality, legal, ethical, regulatory, and reimbursement best practices. The role intends to further connect physicians with the end-to-end processes required for compliant and optimal reimbursement of care and to identify opportunities for increased efficiency and support for the required workflows. As a peer to clinical staff and hospital administration, the physician advisor is at the intersection of monitoring and intervening when practice patterns create disparities between pathway standards, severity of illness, patient and family rights, teamwork, or other issues regarding the stewardship of resources for patients, special populations, and the organization as a whole.

Requirements

Doctorate from an accredited Medical or Osteopathic School
3 years of experience in a clinical practice OR certification as a physician advisor
Prior experience in physician advisory
Board Certified in applicable specialty
Active medical staff privileges at health system obtained within ninety (90) days of hire
Ability to read and write in the English language. Ability to understand and speak English fluently enough to be easily understood by patients, hospital personnel, physicians, and visitors.
Strong critical thinking skills and sound clinical background with a working knowledge of disease processes, anatomy and physiology, and treatment regimens.
Ability to analyze and interpret clinical information in the patient’s medical record.
Excellent verbal and written communication skills with strong attention to detail and accuracy.
Aptitude to interact confidently and communicate effectively with physicians and other members of the clinical team.
Willingness to work collaboratively within a team.
Knowledge of Epic and CMS regulations.
High level Computer literacy and efficiency with technology, including but not limited to, Microsoft Office Suite (including Word, Excel, Teams), Zoom, Epic, 3M360.
Ability to use good judgment in an emergency situation.
Commitment to upholding and providing services in a manner that is congruent with Tufts Medicine’s mission statement.

Nice To Haves

Prior leadership experience

Responsibilities

Provide overall direction and administrative leadership to the unit/department
Provide Leadership on efficiency and productivity of utilization management functions in coordination with department operational leadership
Lead and organize the ongoing evaluation of the utilization program against quality and utilization benchmarks and targets
Identify opportunities for improvement, including organizing and managing costs of department processes
Collaborate with health system leaders, including Quality Improvement, Analytics, Care Management, Finance, and other stake holders as needed.
Support department staff to assure quality, inter-rater reliability and standards are met in daily operations including resolution and communication of utilization management issues and concerns.
Collect data following established procedures and analyzes findings for purposes of continuous quality improvement and for internal and external reporting.
Provide medical staff education around utilization management principles and activities.
Oversee utilization management and criteria-based reviews of care, clinical appeals regarding medical necessity (including peer-to-peers), and the interaction with claims payment policies and processes.
Act as medical lead business and clinical liaison to health system providers and facilitate support for the effective execution of department programs
Co-chair the utilization management committee
Supervise and have direct responsibility for Physician Advisors, including accountability for yearly performance reviews, insuring quality control of work products, and development of applicable skillsets.
Achieve key financial and/or operational outcomes as determined by department leadership
Establish systems and process that drive accountability for utilization management principles, including financial and/or operational outcomes.
Work effectively with cross company partners to execute divisional and departmental initiatives and day-to-day operations.
Act as an effective communication conduit horizontally and vertically throughout the organization.
Develop talent within the team, including acquiring, engaging, and retaining.
Staff, organize, and schedule the team to leverage maximum labor productivity.
Establish metrics that measure key business outcomes.
Translate organizational vision and strategies to department level and mobilize allocated resources to achieve profitable growth.
Effectively anticipate obstacles and barriers and work creatively to avoid or overcome them.