Physician Advisor Denials Management

CommonSpirit Health•Englewood, CO

About The Position

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system. Job Summary and Responsibilities As a Physician Advisor, you will promote evidence-based medical care and appropriate hospital resource utilization, facilitating communication across medical, nursing, care coordination, and administrative departments. Every day you will advocate for efficient patient care, remove barriers, and collaborate with attending physicians, bolstering the Department of Care Coordination's utilization and compliance efforts. To be successful, you need exceptional clinical acumen, strong communication, and a deep understanding of hospital operations/regulations. Your ability to influence, drive efficiency, and advocate will be paramount for optimizing care and resource allocation.

Requirements

Minimum 3 years of experience as a Physician Advisor
Minimum 5 years of experience in Clinical Practice
Experience performing Peer to Peer Reviews
Experience submitting written and verbal appeals
Utilization management experience
Valid and active MD or DO License

Responsibilities

Conducts medical record review in appropriate cases for medical necessity of inpatient admission, need for continued hospital stay, adequacy of discharge planning and quality care management.
Understand the intricacies of ICD-9-CM, ICD-10-CM/PCS, MS-DRG, APR-DRG, and the Medicare Inpatient Prospective Payment System (IPPS) to make medical determinations on severity of illness, acuity, risk of mortality, and communicate with treating physicians in cooperation with the utilization team and health information personnel
Serve as a liaison between the national care management team, medical staff, and medical executives to encourage physician cooperation and understanding of documentation importance
Assist in communications of internal physician advisor services in the hospital newsletters and other communication vehicles to further educate the medical staff
Communicate feedback on program results to facility leadership (i.e. CMO, Care Management Directors, Quality Directors)
Provides feedback and education to the Care Management and Clinical Documentation Departments through written and verbal communication as well as appropriate tracking and trending for process improvement efforts.
Attends and participates in facility committee meetings, by invitation, as applicable: Clinical Documentation Steering Committee Extended Length of Stay Rounds Utilization Review Committee Care Management Staff Meetings
Contacts Attending Physicians: Makes face-to-face and telephonic/electronic contacts and presentations to all medical staff physicians and potential physician groups introducing referral services, new products and present product offerings.
Conducts Peer to Peer discussions with payers as needed: Acts as a liaison and coordinator with operations for physicians.
Attends applicable committee meetings, such as a Joint Operating Committee (JOC), as requested by Utilization Management or Managed Care:
Works with the Care Management Director and staff to facilitate client profiles, clinical service utilization and support for revenue management activities.