Physician Advisor - Erie, Pa

Highmark Health•Erie, PA

5d•Onsite

About The Position

The Physician Advisor is responsible for assuring the most cost-effective, appropriate use of health care services for patients treated at Allegheny Health Network. This role involves correlating patient clinical information with government and commercial payer regulations and criteria regarding severity of illness, intensity of service, and appropriateness of care setting. The Physician Advisor conducts level of care reviews and peer-to-peer discussions with payers, collaborates with the hospital’s interdisciplinary care team (Physicians, Case Managers, UM nurses, hospital leadership), and participates in the Utilization Management Committee and hospital/enterprise-level quality and throughput initiatives. This position reports to the Chief Quality Officer and Medical Director of Physician Advisors.

Requirements

Minimum of 5 years of clinical practice experience in a hospital setting.
Doctor of Medicine (MD) or Doctor of Osteopathy (DO).
Board Certified in any Medical Subspecialty.
Licensed in the state of Pennsylvania prior to employment.

Nice To Haves

Board Certified in Quality/Physician Advising.
Physician Advisor experience in a clinical setting.
Physician Advisor experience with cross-functional teams.
Physician Advisor experience with a large health system.
Physician Advisor experience with an integrated payer/provider network.

Responsibilities

Evaluate the medical necessity and appropriateness of hospital admissions, observation status and services, continued hospital stays, and ancillary services in conjunction with the admitting physician, Case Management, and other hospital personnel.
Discuss cases with attending physicians regarding medical necessity when appropriate.
Discuss cases with insurance company medical directors to obtain payer authorization or conduct peer-to-peer discussions in cases of denial.
Provide medical expertise, advice, and support to the Case Management Department.
Educate medical staff regarding medical necessity and appropriateness of health care services.
Provide ongoing education to residents/colleagues regarding observation status and case management.
Assist with appeal letters and participate in data collection for utilization management.
Receive daily reports on observation cases and review their status, facilitate institutional processes, and communicate with attending physicians and case managers.
Conduct interdisciplinary rounds to drive quality and reduce length of stay.
Interact with coding and clinical documentation specialists.
Actively participate in the Utilization Management Committee.
Lead and report data on case management and observation services in the monthly Throughput Meeting.
Review and analyze metric reporting dashboards and implement action plans if goals are not met.