Physician Advisor

St. Joseph's Health•Paterson, NJ

6d•$160 - $180•Onsite

About The Position

The Physician Advisor (PA) role is responsible for completing detailed reviews of complex patient cases to ensure appropriate plan of care and resource management. An enhanced case review by the PA is necessary to reduce denials and resource utilization issues. PA responsibilities include but are not limited to enhanced utilization review, comprehensive management of denials and appeals, effective partnership with Care Management and Social Work, expertise in insurance regulation and compliance, and availability for provider education. The PA conducts clinical reviews on cases referred by care management staff, physicians, and/or other health care professionals to meet regulatory requirements and in accordance with the hospital’s objectives for assuring quality patient care and effective, efficient utilization of health care services. The PA meets regularly with care management and health care team members to discuss selected cases and make recommendations for care, interacting with medical staff members, service line medical directors and medical directors of third-party payers to discuss the needs of patients 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 assist providers to accurately document the patient’s medical necessity and opportunities for conversions. PAs will help appropriately manage patients’ course of treatment to ensure expedited level of care.

Requirements

Physician Advisor role requires detailed review of complex patient cases.
Must ensure appropriate plan of care and resource management.
Must reduce denials and resource utilization issues.
Must conduct enhanced utilization review.
Must manage denials and appeals.
Must partner with Care Management and Social Work.
Must have expertise in insurance regulation and compliance.
Must be available for provider education.
Must conduct clinical reviews on cases referred by care management staff, physicians, and/or other health care professionals.
Must meet regulatory requirements.
Must align with hospital’s objectives for assuring quality patient care and effective, efficient utilization of health care services.
Must meet regularly with care management and health care team members to discuss selected cases and make recommendations for care.
Must interact with medical staff members, service line medical directors and medical directors of third-party payers to discuss the needs of patients and alternative levels of care.
Must act as consultant to and resource for attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources.
Must act as a resource for the medical staff regarding federal and state utilization and quality regulations.
Must assist providers to accurately document the patient’s medical necessity and opportunities for conversions.
Must help appropriately manage patients’ course of treatment to ensure expedited level of care.

Responsibilities

Completing detailed reviews of complex patient cases to ensure appropriate plan of care and resource management.
Reducing denials and resource utilization issues through enhanced case review.
Conducting enhanced utilization reviews.
Managing denials and appeals comprehensively.
Partnering effectively with Care Management and Social Work.
Providing expertise in insurance regulation and compliance.
Being available for provider education.
Conducting clinical reviews on referred cases to meet regulatory requirements and hospital objectives.
Meeting regularly with care management and health care team members to discuss selected cases and make recommendations for care.
Interacting with medical staff members, service line medical directors, and medical directors of third-party payers to discuss patient needs and alternative levels of care.
Acting as a consultant and resource for attending physicians regarding hospitalization appropriateness, continued stay, and resource utilization.
Acting as a resource for the medical staff regarding federal and state utilization and quality regulations.
Assisting providers to accurately document patient’s medical necessity and opportunities for conversions.
Helping appropriately manage patients’ course of treatment to ensure expedited level of care.