MD-Physician Advisor-CDS-PRN

Presbyterian Healthcare Services•New York, NY

33d•Onsite

About The Position

The Physician Advisor is a key member of the healthcare organizations leadership team and is charged with meeting the organizations goals and objectives for assuring the effective, efficient utilization of health care services. The Physician Advisor is a physician serving the hospital through teaching, consulting and advising the Medical Staff, the Utilization Review team, the Case management team and hospital leadership. The Physician Advisor shall develop expertise on matters regarding physician practice patterns, over and under-utilization of resources, medical necessity, levels of care progression, denial management, compliance with governmental and private payer regulations, appropriate physician coding and documentation requirements. PRIMARY SCOPE OF SERVICE: The Physician Advisor works closely with Medical Staff leadership, the entire medical staff, case management, social services, discharge planning and utilization management to develop and implement methods to optimize use of hospital services for all patients while also ensuring the quality of care provided. This includes working with providers, hospital leadership, case management to optimize length of hospital stay, ensuring efficient management of resources and ensuring patients are in the appropriate level of care. This involves reviewing documentation to support current level of care, monitoring appropriate use of diagnostic and therapeutic modalities and ensuring compliance with government and payer rules for continued hospital care.

Requirements

Excellent customer service and interpersonal skills
Strong analytical skills, written and verbal communication skills with all levels of internal and external customers
Strong organizational skills and ability to set priorities and multi-task, demonstrate flexibility, teamwork and is accustomed to change in the healthcare environment
Ability to effectively present information, both formal and informal
Board Certified Physician
Hold and maintain unrestricted medical license in NM
Maintain active membership on Hospital Medical Staff
Possess or acquire solid foundation, knowledge and experience in the areas of CMS guidelines, utilization management, quality improvement and patient safety
Possess working knowledge of hospital and case management operations
Strong computer skills and working knowledge of the EMR

Nice To Haves

Familiarity with MCG clinical guidelines preferred
Membership in the American College of Physician Advisors (ACPA) preferred
Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes

Responsibilities

Participates in required orientation and training related to the Physician Advisor role
Meets production standards within established time requirements.
Work product and performance meet quality standards
Maintains confidentiality of patient care and business matters
Participates in ongoing training and education related to the Physician Advisor role, Utilization Management, Care Management and other related areas as requested
Help ensure compliance with regulatory bodies such as CMS and Joint Commission
Provides consultation to nurses and case management regarding complex clinical issues and advises on justification required for continued stay, medical necessity and utilization management.
Responds to request for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management or Utilization Review department in a timely fashion.
Maintains accountability for fulfilling the obligations and responsibilities of the role to support the medical staff in the clinical progression of patient care.
Works closely with Case Management on complex patient issues/discharge barriers to problem solve and expedite transfer to appropriate level of care
Assist with length of stay management and utilization of resources
Review medical records of patients identified by case managers or social workers or as requested by the health care team in order to perform quality and utilization oversight
Perform medical necessity reviews including initial level of care, secondary reviews and continued stay reviews and document review determinations and actions
Assist with denial management process by performing case reviews, performing Peer to Peer reviews and determining if formal appeal warranted
Perform Government One day stay (Inpatient ) reviews and document determinations
Provide regular feedback to physicians and all other stakeholders regarding level of care, length of stay and potential quality issues
Recommend and request additional and more complete medical record documentation to support placement status or medical necessity
Review cases that indicate a need for a hospital issued notice of non-coverage (HINN).
Discuss case with the attending physician and if additional clinical information is not available to support continued hospitalization, coordinate the process with Case Management for issuance of the HINN
Participate in interdisciplinary rounds with the healthcare team
Participate in Complex (long length of stay) rounds with Case Management team to facilitate use of the most appropriate level of care setting
Act as liaison with payers to facilitate approvals and prevent denials by participating in peer to peer discussions and reviews
Facilitate, mentor and educate physicians regarding payer requirements
Provide education to physicians and other clinicians related to regulatory requirements, appropriate utilization of hospital services, community resources and alternative levels of care
Provide education to physicians and other clinicians regarding inappropriate admissions and work with Service Line Medical Directors if actions plans needed to address issues
Provide physician coaching and ongoing education on appropriate clinical documentation improvement and care standards as may be appropriate
Conduct physician education sessions to share data, trends, practice patterns and other relevant information
Investigate avoidable delay concerns referred by case management team
Contact physicians in a timely manner to resolve delays and achieve positive outcomes
Identify denial trends and work with medical staff, Senior Physician Advisor and hospital administration to resolve any issues
Support CDI team in helping physicians to improve documentation
Effectively communicate physician teaching points for immediate and future clinical case studies
Explain the importance of clinical documentation to support level of care and to avoid denials by payers
Attend pertinent meetings as requested by Senior Physician Advisor and Hospital Administration
Serve on the Utilization Management Committee
Conduct presentations to Medical Staff, Hospital Board/Administration as warranted as may be related to Physician Advisor areas of expertise or knowledge
Participate in peer review process as may be necessary or warranted
Become familiar with the CMS Conditions of Participation related to Utilization Review
Work with contracting to maintain current knowledge of payer regulatory and contract requirements
Attend continuing education sessions pertaining to utilization and quality management
Interacts with Presbyterian Health Plan Leadership to ensure coordinated processes are in place specific to utilization management of PHP members admitted to CDS

Benefits

Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more!
In addition, we offer all employees a robust, day one effective benefits plan consisting of medical, dental, vision and more.
Exceptional retirement plans - 403b retirement savings program with both matching programs and employer contributions.

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