Physician Advisor – Pittsburgh, PA

Highmark Health • Pittsburgh, PA

2d • Onsite

About The Position

The Allegheny Health Network (AHN) is recruiting a full-time Physician Advisor to join our team located in Pittsburgh, PA. This job assures the most cost-effective, appropriate use of health care services for patients treated at Allegheny Health Network while correlating patient clinical information with both government and commercial payer utilized regulations and criteria regarding severity of illness, intensity of service, and the appropriateness of the setting for the administration of that care. The Physician Advisor is responsible for level of care reviews and peer-to-peer discussions with payers if denials do arise. The role requires significant collaboration with the hospital’s interdisciplinary care team including Physicians, Case Managers, UM nurses, and the hospital leadership team. The Physician Advisor is an integral part of the Utilization Management Committee and participates in hospital and enterprise-level quality and throughput initiatives. This position reports to the Chief Quality Officer and Medical Director of Physician Advisors.

Requirements

• 5 years of clinical practice experience in a hospital setting required
• 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 large health system
• Physician Advisor experience with integrated payer/provider network

Responsibilities

• Evaluate the medical necessity and appropriateness of admission to the hospital, utilization of observation status and services for those patients, continued stay in the hospital, and ancillary services ordered.
• Discuss the case with the attending physician regarding medical necessity when appropriate.
• Discuss the case with the insurance company medical director to obtain payer authorization or conduct a peer-to-peer discussion in cases of a denial when requested.
• Provide medical expertise, advice, and support to the Case Management Department.
• Provide education to the 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 activities for utilization management.
• Receive daily report from Nursing Service (Bed Management) and Case Management on all observation cases.
• Review the status of observation cases, facilitate use of institutional processes and communicate with attending physicians and case managers regarding the patient's status.
• Conduct interdisciplinary rounds to drive quality and reduce length of stay in concert with case management, physicians, and the rest of the multidisciplinary team.
• Interact regularly with coding and clinical documentation specialists.
• Be an active member of the Utilization Management Committee.
• Lead and report data on case management and observation services on the monthly Throughput Meeting.
• Review and analyze metric reporting dashboards and implement action plans if not meeting goals.

Benefits

• Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level