MD-Physician Advisor-CDS-PRN

Presbyterian System Services • Albuquerque, NM

4d • Onsite

About The Position

The Physician Advisor is a key member of the healthcare organization's leadership team, responsible for meeting the organization's goals and objectives for effective and efficient utilization of healthcare services. This physician role involves teaching, consulting, and advising the Medical Staff, Utilization Review team, Case Management team, and hospital leadership. The Physician Advisor develops expertise in physician practice patterns, resource utilization (over and under-utilization), medical necessity, levels of care progression, denial management, compliance with governmental and private payer regulations, and appropriate physician coding and documentation. They collaborate closely with Medical Staff leadership, the entire medical staff, case management, social services, discharge planning, and utilization management to optimize the use of hospital services for all patients while ensuring quality of care. This includes optimizing length of hospital stay, ensuring efficient resource management, and verifying patients are in the appropriate level of care through documentation review and monitoring of diagnostic and therapeutic modalities.

Requirements

• 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
• Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes

Nice To Haves

• Familiarity with MCG clinical guidelines preferred
• Membership in the American College of Physician Advisors (ACPA) preferred

Responsibilities

• 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 requests 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.
• Assists with length of stay management and utilization of resources.
• Reviews 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.
• Performs medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews and documents review determinations and actions.
• Assists with the denial management process by performing case reviews, performing Peer to Peer reviews, and determining if a formal appeal is warranted.
• Performs Government One day stay (Inpatient) reviews and documents determinations.
• Provides regular feedback to physicians and all other stakeholders regarding level of care, length of stay, and potential quality issues.
• Recommends and requests additional and more complete medical record documentation to support placement status or medical necessity.
• Reviews cases that indicate a need for a hospital-issued notice of non-coverage (HINN).
• Discusses cases with the attending physician and if additional clinical information is not available to support continued hospitalization, coordinates the process with Case Management for issuance of the HINN.
• Participates in interdisciplinary rounds with the healthcare team.
• Participates in Complex (long length of stay) rounds with the Case Management team to facilitate the use of the most appropriate level of care setting.
• Acts as a liaison with payers to facilitate approvals and prevent denials by participating in peer-to-peer discussions and reviews.
• Facilitates, mentors, and educates physicians regarding payer requirements.
• Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization of hospital services, community resources, and alternative levels of care.
• Provides education to physicians and other clinicians regarding inappropriate admissions and works with Service Line Medical Directors if action plans are needed to address issues.
• Provides physician coaching and ongoing education on appropriate clinical documentation improvement and care standards as may be appropriate.
• Conducts physician education sessions to share data, trends, practice patterns, and other relevant information.
• Investigates avoidable delay concerns referred by the case management team.
• Contacts physicians in a timely manner to resolve delays and achieve positive outcomes.
• Identifies denial trends and works with the medical staff, Senior Physician Advisor, and hospital administration to resolve any issues.
• Supports the CDI team in helping physicians to improve documentation.
• Effectively communicates physician teaching points for immediate and future clinical case studies.
• Explains the importance of clinical documentation to support level of care and to avoid denials by payers.
• Attends pertinent meetings as requested by Senior Physician Advisor and Hospital Administration.
• Serves on the Utilization Management Committee.
• Conducts presentations to Medical Staff, Hospital Board/Administration as warranted as may be related to Physician Advisor areas of expertise or knowledge.
• Participates in the peer review process as may be necessary or warranted.
• Becomes familiar with the CMS Conditions of Participation related to Utilization Review.
• Works with contracting to maintain current knowledge of payer regulatory and contract requirements.
• Attends 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

• Robust wellness program, including free access to on-site and community-based gyms, nutrition coaching and classes, wellness challenges
• Robust, day one effective benefits plan consisting of medical, dental, vision
• Exceptional retirement plans - 403b retirement savings program with both matching programs and employer contributions
• Strongline silent alarm badge
• The RESET program (multi-day immersive retreat for clinicians)

What This Job Offers

• Career Level: Senior
• Education Level: No Education Listed