Physician Advisor Director

Under the co‑direction of the Executive Director of Reimbursement, Chief Medical Information Officer, and Associate Chief Medical Officer, the Physician Advisor Director provides leadership to a team of associate Physician Advisors that supports case management, social work, coding team, utilization review, population health, and other clinical members to provide cost efficient, high quality inpatient and observation care at GBMC Hospital. This management includes level of care reviews, all denial reviews and appeals management for all hospital patients. The Physician Advisor Director is responsible for clinical direction of these services and shall be responsible for the development, implementation and oversight of policies and procedures as they apply to the provision of assigned services. The Physician Advisor Director is a 0.75 to 1.0 FTE and will report directly to the Associate Chief Medical Officer. Responsibilities Serve as physician expert and provide support to care teams and Case Management, Utilization Review, and Social Work staff regarding utilization decisions, including screening for appropriateness of hospitalization, Level of Care (LOC), patient billing status management, Length of Stay (LOS) management, continued stay decisions, clinical review of patients, utilization review activities, resource utilization/management, denial management issues and transitions of care/discharge planning advice. Work productively with all department leaders to ensure that clinical care is consistent with current scientific advances and best evidence in published clinical literature or as established by recognized professional associations. Provide input at least annually for strategic and operational planning purposes and assess Case Management, Utilization Review and Discharge/Transfer of Care (DC/TOC) efficiency and effectiveness. Make recommendations to the Hospital’s administration regarding the use of hospital personnel, necessary equipment, and general quality standards of patient care. Lead development and maintenance of effective Utilization Management (UM) coverage at all points of entry to the Hospital (POE’s). Support integration of Physician Advisor, Case Management and Revenue Cycle departments (weekly or bi‑weekly) to ensure claims are paid and medical necessity issues are addressed concurrently. Review denials for patients in the hospital or recently discharged, conduct peer‑to‑peer consultations with attending physicians, review request for accommodation codes, and review daily status reports for Medicare patients. Administer the appeals process, including completion of appeal letters and communication & education of medical staff. Oversee development and approval of all operating policies and procedures for Physician Advisor services with the responsible Administrator. Represent the hospital’s interests to external organizations concerned with denial management, Medicare or insurance providers. Collaborate with PA peers/mentors on an inter‑rater reliability (IRR) process to capture standardized policies and procedures that support overall program strategy and utilization management approach. Provide education to physicians and other clinicians related to regulatory requirements, appropriate utilization, and alternative levels of care. Educate specific medical staff departments at department meetings regarding correct disease reporting, ICD code assignment, capture of severity, and overall hospital reimbursement policies. Liaise with Utilization Review, HIM/CDI, EHR and various quality teams throughout the hospital. Assist in the dissemination of best‑practice information. Ensure commitment to GBMC service excellence standards and achieve a best‑in‑class provider goal by maintaining a positive attitude, professional appearance, respectful behavior, and consistent sharing of physician‑specific service results. Chair the monthly Utilization Management (UM) Medical Staff Committee and moderate or resolve conflicts among physicians and other health care providers. Provide support for staff in difficult situations and work to ensure initial or continued accreditation through collaboration with quality and other departments. Collaborate with hospital and quality department leadership to ensure compliance with accreditation and regulatory requirements, identify gaps in physician practice, develop action plans, provide education on new standards, and support quality improvement projects. Collaborate with Clinical Documentation Integrity (CDI) and Revenue Cycle on strategic initiatives to improve the efficiency of the PA program. All roles must demonstrate GBMC Values: respect, courtesy, fairness, kindness, professionalism, accountability, teamwork, ethical behavior, and results orientation. Qualifications Education : Graduate of an accredited medical program. Licensure/Certification : Licensed as a physician in the State of Maryland and Board Certified by the American Board of Internal Medicine, or other certifying Board as deemed appropriate by the Chief Executive Officer. Experience : 2‑4 years of recent experience and expertise in Utilization Management and Clinical Quality Management and 5 years of direct clinical experience. Knowledge of Pay for Performance (P4P)/Value‑Based Purchasing (VBP) initiatives and incentives. Skills : High level of interpersonal skills for effective communication and interaction with a wide variety of hospital personnel, physicians, and the general public; documented interest and experience in the education and quality improvement needs for the various service lines; familiarity with Clinical Documentation requirements and working knowledge of Centers for Medicare & Medicaid Services (CMS) rules and regulations. Pay Range Pay Range: $148,140.24 – $266,652.44. Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs. Benefits Competitive salary and generous paid time off Free parking Monthly MTA bus pass subsidy – 85% paid by GBMC (if applicable) Company‑subsidized onsite fitness and wellness center (if applicable) Pre‑paid tuition for professional development, additional certifications, and degree programs Comprehensive health, dental and vision coverage 401(a) and 403(b) retirement savings plans Equal Employment Opportunity GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law. #J-18808-Ljbffr Boston Medical Center