Physician Advisor

BlueCross BlueShield of South Carolina•Washington, NV

4d•$176,132 - $355,017•Remote

About The Position

The Physician Advisor optimizes efficient management of resources, ensuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities. In this role, you will provide assessment and determination of medical necessity in case evaluation and utilization management. The Physician Advisor collaborates with a multidisciplinary team to implement methods and develop care management protocols that optimize the use of BlueCross BlueShield of South Carolina services for all patients while ensuring quality care is provided.

Requirements

Medical Doctor (MD) or Osteopathic Doctor (DO) with current license to practice. If Psychiatry Advisor - Doctor of Psychiatry (MD) with current active medical license, without restriction.
8 years-broad clinical experience to include knowledge of utilization and medical review. Experience may include paid training.
Demonstrated ability to direct multiple strategic projects.
Excellent verbal and written communication skills.
Excellent judgment, organizational, customer service, presentation skills.
Excellent analytical or critical thinking skills.
Knowledge of strategic concepts.
Ability to persuade, negotiate, or influence others.
Microsoft Office
Active, unrestricted medical license from the United States and in the state of hire and current board certification in a recognized specialty.

Nice To Haves

Experience with prior authorization review.
2 years-medical data analysis/analytical capability to interpret statistical information.
Experience with medical oversight of quality improvement activities.
Experience with quality committees or NCQA.
Experience with population based disease management or public health initiatives.
Experience in medical management or managed care.
Demonstrated understanding of Medicare programs.

Responsibilities

Communicates with hospital physicians, care coordination and utilization management (UM) staff to champion best practices for evidence-based care and its documentation. Provides valuable guidance on matters regarding physician practice patterns, over- and under-utilization of resources, medical necessity, documentation best practices, level of care progression, denial management, and compliance with governmental regulations.
Performs UM review functions including pre-admission reviews, continues stay reviews, procedure precertifications, post-service reviews, emergency room visit reviews, and individual case management needs.
Responds to requests for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management department in a timely fashion.
Keeps abreast of current CMS and MCG evidence-based guidelines to enable UM decisions. Maintains compliance with legal, regulatory and accreditation requirements and payor partner policies.
Uses, protects and discloses patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Serves as medical resource for quality improvement. Functions as liaison to medical community.
Acts as resource for providers/internal staff on medical policies. Educates providers on issues concerning medical policies, utilization specifications, and coding/medical necessity issues.
Conducts research into new/controversial medical procedures/technology as assigned to propose possible policy, coverage criteria, utilization specifications and coding recommendations.
Participates in medical review policy/quality programs and inter-reviewer reliability studies.