Physician Advisor | Case Management

Houston Methodist•Houston, TX

About The Position

Physician Advisor | Case Management FLSA STATUS Exempt QUALIFICATIONS EDUCATION Graduate of accredited medical school EXPERIENCE Five years experience in clinical practice LICENSES AND CERTIFICATIONS Required MD - Physician - State Licensure - Texas Department of Licensing and Regulation_PSV Unrestricted medical license in the State of Texas SKILLS AND ABILITIES Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles Ability to foster positive medical staff relations and work effectively with all healthcare disciplines. Demonstrates understanding and knowledge of utilization management, clinical documentation, and state and federal healthcare regulations. Active practitioner ESSENTIAL FUNCTIONS PEOPLE ESSENTIAL FUNCTIONS Interact with medical staff members to discuss needs of patients and alternative levels of care. Provide consultation to case management staff regarding complex clinical issues and advises on next steps. Provide feedback to attending and consulting physicians regarding level of care, length of stay, and quality issues. Chair the utilization review/management committee, actively participates in defining operational strategic objectives for the Utilization Management Program and serve as the liaison to other medical staff committees that interface with the utilization review/management committee. Assist with the evaluation of the hospital's Utilization Management Program, including annual review and revision of the hospital's UR plan. Contacts physicians to resolve delays and achieve positive outcomes and ensures physician accountability for efficient patient care management. Communicates to medical staff leaders (e.g., department chairs, medical directors and other attending physicians as necessary) relevant findings of physician's performance when patterns of clinical outcomes demonstrate undesirable variation. SERVICE ESSENTIAL FUNCTIONS Create strategies to enhance hospital and post-acute interdisciplinary efforts for maximizing patients/family outcomes. Serve as an advocate for case management services and clinical documentation. Collaborate with medical staff in the development and measurement of performance standards involving patient care and utilizations of resources to achieve optimal outcomes. Round on the patient care units, and throughout the hospital, to identify opportunities, to impact resource utilization and manage length of stay (e.g., outliers, medical management practices, problematic patient/family dynamics). Provides support and assists Clinical Documentation Specialists and Coders on an ongoing basis by addressing specific documentation issues encountered by CDSs/Coders, including noncompliant physicians. Determines the “focus” of presentations of clinical examples regarding documentation opportunities and specifics based on quarterly trends and presents this information in department meetings. QUALITY/SAFETY ESSENTIAL FUNCTIONS Act as consultant and resource to attending/responsible physicians regarding their decisions relative to appropriateness of hospitalization, continued stay and use of resources in length of stay management. Use InterQual criteria and document patient care reviews, decisions, and other pertinent information per hospital/case management and clinical documentation policies policy. Review issues identified by case management department to ensure appropriate follow-up, recommends improvement initiatives as needed and makes referrals to appropriate department chairs as necessary. Determine if standards of quality care, as defined by the hospital's Medical Executive Committee are met. Seek additional clinical information from the attending and consulting physicians as required to make effective level of care determinations, and in doing so, recommends and requests additional, or more complete, medical record documentation to support such determinations. FINANCE ESSENTIAL FUNCTIONS Review medical records identified by case managers, or as requested by other members of the healthcare team, in order to assist with the identification and management of denials. Make suggestions related to resource utilization and service management. Actively participate in the hospital's claim denial process, including, but not limited to, responding to denials from payers on a concurrent basis; authoring denial letters as needed on retrospective denials; and determining to what extent denied cases will be appealed. Review cases that indicate need for issuance of a “hospital notice of non-coverage”. GROWTH/INNOVATION ESSENTIAL FUNCTIONS Maintain knowledge of current state, federal, and CMS regulations, DNV requirements, and guidelines on case management, utilization review, and clinical documentation. Provide ongoing education to physicians and other providers on the link between ICD-10 and clinical terminology to improve understanding of severity of illness, risk of mortality and DRG assignments of their individual patient records, as these relate to individual physician/provider scorecards and collective (e.g. division, department, entity specific) quality profiling and reimbursement. Education may include department or division meetings, individual provider meetings, articles in entity-specific newsletters and other communication vehicles as identified/developed. Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization of alternate levels of care and community resources. Works with physicians to facilitate referrals across the continuum of care. Facilitates, mentors, educates other physicians regarding payor requirements and lnterQual Criteria and CMS guidelines for medical necessity.

Requirements

Graduate of accredited medical school
Five years experience in clinical practice
Unrestricted medical license in the State of Texas
Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
Ability to foster positive medical staff relations and work effectively with all healthcare disciplines.
Demonstrates understanding and knowledge of utilization management, clinical documentation, and state and federal healthcare regulations.
Active practitioner

Responsibilities

Interact with medical staff members to discuss needs of patients and alternative levels of care.
Provide consultation to case management staff regarding complex clinical issues and advises on next steps.
Provide feedback to attending and consulting physicians regarding level of care, length of stay, and quality issues.
Chair the utilization review/management committee, actively participates in defining operational strategic objectives for the Utilization Management Program and serve as the liaison to other medical staff committees that interface with the utilization review/management committee.
Assist with the evaluation of the hospital's Utilization Management Program, including annual review and revision of the hospital's UR plan.
Contacts physicians to resolve delays and achieve positive outcomes and ensures physician accountability for efficient patient care management.
Communicates to medical staff leaders (e.g., department chairs, medical directors and other attending physicians as necessary) relevant findings of physician's performance when patterns of clinical outcomes demonstrate undesirable variation.
Create strategies to enhance hospital and post-acute interdisciplinary efforts for maximizing patients/family outcomes.
Serve as an advocate for case management services and clinical documentation.
Collaborate with medical staff in the development and measurement of performance standards involving patient care and utilizations of resources to achieve optimal outcomes.
Round on the patient care units, and throughout the hospital, to identify opportunities, to impact resource utilization and manage length of stay (e.g., outliers, medical management practices, problematic patient/family dynamics).
Provides support and assists Clinical Documentation Specialists and Coders on an ongoing basis by addressing specific documentation issues encountered by CDSs/Coders, including noncompliant physicians.
Determines the “focus” of presentations of clinical examples regarding documentation opportunities and specifics based on quarterly trends and presents this information in department meetings.
Act as consultant and resource to attending/responsible physicians regarding their decisions relative to appropriateness of hospitalization, continued stay and use of resources in length of stay management.
Use InterQual criteria and document patient care reviews, decisions, and other pertinent information per hospital/case management and clinical documentation policies policy.
Review issues identified by case management department to ensure appropriate follow-up, recommends improvement initiatives as needed and makes referrals to appropriate department chairs as necessary.
Determine if standards of quality care, as defined by the hospital's Medical Executive Committee are met.
Seek additional clinical information from the attending and consulting physicians as required to make effective level of care determinations, and in doing so, recommends and requests additional, or more complete, medical record documentation to support such determinations.
Review medical records identified by case managers, or as requested by other members of the healthcare team, in order to assist with the identification and management of denials.
Make suggestions related to resource utilization and service management.
Actively participate in the hospital's claim denial process, including, but not limited to, responding to denials from payers on a concurrent basis; authoring denial letters as needed on retrospective denials; and determining to what extent denied cases will be appealed.
Review cases that indicate need for issuance of a “hospital notice of non-coverage”.
Maintain knowledge of current state, federal, and CMS regulations, DNV requirements, and guidelines on case management, utilization review, and clinical documentation.
Provide ongoing education to physicians and other providers on the link between ICD-10 and clinical terminology to improve understanding of severity of illness, risk of mortality and DRG assignments of their individual patient records, as these relate to individual physician/provider scorecards and collective (e.g. division, department, entity specific) quality profiling and reimbursement.
Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization of alternate levels of care and community resources.
Works with physicians to facilitate referrals across the continuum of care.
Facilitates, mentors, educates other physicians regarding payor requirements and lnterQual Criteria and CMS guidelines for medical necessity.