Physician Advisor - Erie, Pa

Highmark Health•Erie, PA

1d•Onsite

About The Position

The Physician Advisor is responsible for ensuring the most cost-effective and appropriate use of healthcare services for patients at Allegheny Health Network. This role involves correlating patient clinical information with payer regulations and criteria regarding severity of illness, intensity of service, and appropriateness of care setting. The Physician Advisor conducts level of care reviews, peer-to-peer discussions with payers for denials, and collaborates with the hospital's interdisciplinary care team, including physicians, case managers, UM nurses, and hospital leadership. They are a key member of the Utilization Management Committee and contribute to 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 hospital admissions, observation status and services, continued hospital stays, and ancillary services in collaboration with the admitting physician, Case Management, and other hospital personnel.
Discuss cases with attending physicians regarding medical necessity when appropriate.
Discuss cases with insurance company medical directors to obtain payer authorization or conduct peer-to-peer discussions in cases of denial.
Provide medical expertise, advice, and support to the Case Management Department.
Educate medical staff on medical necessity and appropriateness of healthcare services.
Provide ongoing education to residents/colleagues regarding observation status and case management.
Assist with appeal letters and participate in data collection for utilization management.
Receive daily reports on observation cases from Nursing Service (Bed Management) and Case Management.
Review the status of observation cases, facilitate institutional processes, and communicate with attending physicians and case managers regarding patient status.
Conduct interdisciplinary rounds with case management, physicians, and the multidisciplinary team to drive quality and reduce length of stay.
Interact regularly with coding and clinical documentation specialists.
Actively participate in the Utilization Management Committee.
Lead and report data on case management and observation services in the monthly Throughput Meeting.
Review and analyze metric reporting dashboards and implement action plans for areas not meeting goals.