Physician Advisor- Utilization Management & Clinical Documentation Integrity

Trinity Health•Athens, GA

16d

About The Position

The Physician Advisor serves as a physician leader responsible for improving clinical documentation accuracy, case mix index (CMI), medical necessity compliance, utilization management, and hospital throughput. The Physician Advisor works collaboratively with physicians, case management, clinical documentation integrity (CDI), quality, and revenue cycle teams to ensure appropriate patient status determinations, documentation accuracy, regulatory compliance, and optimal use of hospital resources. This role provides in person, peer-to-peer physician engagement and education to support compliant documentation, reduce denials, decrease avoidable length of stay, and ensure appropriate utilization of hospital services.

Requirements

MD or DO degree from an accredited institution
Board Certified in a recognized medical specialty
Active unrestricted medical license to practice medicine in the state of Georgia.
Minimum of 5 years clinical practice experience
Experience working in hospital-based care
Demonstrated leadership, people management, and team building skills
Must have excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.
Ability to develop and implement strategic clinical plans
Excellent oral and written communication skills
Ability to interact effectively with key internal and external constituents using collaboration and customer service skills that promote excellence in the patient experience.
Customer service orientation
Demonstrated confidence, initiative, and integrity in work practices
Goal-directed and well organized
High level of dependability and accuracy
Ability to work independently
Strong negotiation and persuasion skills
Adept at conflict management
Ability to function within a stressful environment
Strong computer skills and working knowledge of EMR’s
A broad knowledge base of health care delivery and case management within a managed care environment
Comprehensive knowledge of Utilization Review, levels of care, and observation status

Nice To Haves

Prior experience as a Physician Advisor, Medical Director, or Utilization Review physician
Experience with: Clinical Documentation Integrity (CDI) Utilization Management Revenue cycle operations Denials management Length of stay improvement initiatives
Knowledge of: MS-DRG reimbursement Case Mix Index CMS inpatient admission criteria
Certification such as: CHCQM-PHYADV (Certified Physician Advisor)
Additional advanced degree (MBA, MPH, MMM, etc)
Awareness of healthcare reimbursement systems (HMO, PPO, PPS,CMS)

Responsibilities

Partner with CDI specialists to improve clinical documentation accuracy and completeness
Provide physician-to-physician education on documentation requirements related to: Severity of illness Risk of mortality CC/MCC capture DRG assignment
Assist with case mix index (CMI) improvement initiatives
Review complex cases for documentation opportunities that accurately reflect patient acuity
Provide physician guidance for medical necessity determinations
Review cases for appropriate inpatient vs observation status
Support case management staff with complex utilization reviews
Conduct peer-to-peer reviews with payers
Collaborate with care management teams to identify and address barriers to timely discharge
Work with clinical teams to reduce avoidable length of stay and excess days
Participate in daily multidisciplinary rounds and discussions to address throughput challenges and delayed discharges
Work with our Internal Medicine Residents to teach them what a Physician Advisor does and how to align and balance patient care with the KPI’s the Physician Advisor works on to improve.
Review cases with extended length of stay to identify clinical, operational, or documentation barriers contributing to opportunity days
Partner with case management, nursing leadership, and service line leaders to address drivers of avoidable hospital days
Provide physician leadership in resolving delays related to: Clinical decision-making Documentation gaps Discharge readiness Specialist consultation delays
Support hospital initiatives aimed at improving patient flow and capacity management
Review payer denials related to: Medical necessity Level of care DRG downgrades
Write and support clinical appeal letters
Participate in denials management strategy
Identify systemic issues contributing to denials and implement improvement strategies
Provide education to medical staff on documentation, utilization management, and efficient care delivery
Present findings at: Medical staff meetings Service line meetings Quality committees
Serve as a physician champion for documentation improvement, medical necessity compliance, and hospital throughput
Ensure hospital practices align with: CMS Conditions of Participation Medicare documentation rules Two-midnight rule Utilization review regulations
Partner with Quality and Compliance departments to ensure regulatory alignment
Monitor, analyze, and actively strive to improve key hospital performance metrics including, but not limited to: Case Mix Index (CMI) Length of Stay Index (Observed vs Expected LOS and %GMLOS) Opportunity Days Observation rates Medical necessity denial rates CC/MCC capture rate
Identify opportunities for clinical, operational, and documentation improvement