Physician Advisor - Utilization Management

Sutter Health•Sacramento, CA

2d•$118,321 - $189,322

About The Position

The Physician Advisor (PA) is a key member of the hospital's leadership team charged with meeting the organization's goals and objectives for ensuring the effective, efficient utilization of health care services. The PA will develop expertise on matters regarding physician practice patterns, over- and under-utilization of resources, medical necessity, documentation best practices, level of care progression, denial management and compliance with governmental regulations and conditions of participation and commercial insurance contracts. The PA is responsible for establishing, maintaining and strengthening the relationship with System Enterprise and the hospital to appropriately optimize the use of Sutter Health Internal Physician Advisor Services (IPAS). The physician Advisor will work closely with the medical staff, including house staff, and all utilization management (UM) personnel, Care Management (CM) personnel to develop and implement methods and strategies to optimize the use of hospital services. This includes care management processes that ensure patients are in the appropriate level of care with supporting documentation of regulatory compliance and accurate coding. The Physician Advisor (PA) conducts clinical reviews on cases referred by UM/CM staff and or other healthcare professionals to meet regulatory requirements in accordance with the hospital objectives for assuring quality patient care and effective, efficient utilization of health care services. The PA meets with care management, UM staff and health care team members and medical directors of third-party payers to discuss the needs of patient's and alternative levels of care. The PA acts as consultant to and resource for attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources. The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations. The PA will act as a liaison between the CDI (Clinical Documentation Improvement) professional, HIM (Health Information Management ) ,and the hospital's medical staff to facilitate accurate and complete documentation for coding and abstracting of clinical data, capture of severity, acuity and risk for mortality, in addition to Direct Report Groups (DRG) assignment.

Requirements

Doctorate: Graduate of an accredited medical school
MD-Doctor of Medicine OR DO-Doctor of Osteopathy
Unrestricted medical license in state of residence
3 years of recent relevant experience.
Excellent interpersonal communication and negotiation skills.
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.
Some awareness of healthcare reimbursement systems: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Patient Processing Service (PPS),Centers for Medicare and Medicaid Services (GR) Grouper (CMS) preferred.
Post-acute levels of care such as Home Health, Hospice, Advance Illness Management (AIM), and Palliative Care.
Skilled Nursing Facility (SNF), Long Term Acute Care (LTAC), B&C, Sub-acute, Acute rehab.
Proficient Knowledge of coding and DRG assignment process preferred.
Must be able to effectively communicate with, and promote cooperation and collaboration between individuals including patients/families/caretakers, physicians, nurses and other ancillary partners.
Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families.
Demonstrates commitment to service excellence in all patient, family and employee interactions and in performing all job responsibilities.
Functions in a manner to promote quality patient care and assure a positive patient experience.
Excellent verbal and written communication skills.
Must have excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.
Intermediate computer skills.
Ability to promote teamwork and to effectively function in teams.
Ability to interact effectively with key internal and external constituents using collaboration, and customer service skills that promote excellence in the patient experience.

Nice To Haves

Some awareness of healthcare reimbursement systems: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Patient Processing Service (PPS),Centers for Medicare and Medicaid Services (GR) Grouper (CMS) preferred.
Proficient Knowledge of coding and DRG assignment process preferred.

Responsibilities

Provides PA support and clinical oversight to all programs managed through Care Management Operations: Clinical Denials and Appeals, Recovery Audit Contractor (RAC), Medicare Two Midnight Rule review, Concurrent denials review and processing, Peer to Peer discussion with payers, and Inpatient authorization clinical escalations.
Works with Care Management Operations team to develop and implement care management standards, trends and analyze data to identify opportunities and design strategies and solutions to help improve care management processes.
Actively participates and contributes to Care Management projects design and implementation and acts as a consultant and clinical expert for the department in all matters including Managed Care Contracting and payer disputes, Government and non-government audits.
Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, alternative levels of care, community resources, and end of life care.
Works with physicians to facilitate continuum of care.
Provides education to physicians and other clinicians regarding inappropriate admissions and create action plans to address.
Identifies quality, safety, patient satisfaction and efficiency issues leading to suboptimal care and take appropriate actions to resolve it.
Promotes and educates healthcare team on a team approach to patient care.
Promotes coordination, communication and collaboration among all team members.
Supports the organization in quality improvement efforts requiring physician input and / or involvement.
Educates individual hospital staff physicians about International Classification for Disease (ICD) coding guidelines, and clinical terminology to improve their understanding of severity, acuity, risk of mortality and DRG assignments on their individual patient records.
Works to provide improved health records documentation that specifically affect ICD code assignment.
Reviews clinical documentation and data for trending and analysis and develop strategies to improve improved clinical documentation.
Develops and maintains positive, productive, professional relationships with the healthcare team and representatives of the community agencies.
Relates with tact and respect to all customers with diverse cultural and socioeconomic backgrounds without personal judgment, some of whom may be exhibiting varying levels of distress.
Functionally supervises and positively contributes to the team’s decision making process.
Willingly provides and accepts direct, constructive feedback to and from colleagues and the leadership team.
Actively uses effective communication skills with colleagues to resolve issues in a timely manner.