Lead Physician Advisor — Utilization & Clinical Ops

Job Profile Summary This role focuses on performing health assessments, running diagnostic tests, prescribing medication and creating treatment plans as well as providing health and wellness education to patients. In addition, this role focuses on performing the following Physician duties: Diagnoses and treats injuries or illnesses and address health maintenance of patients. Responsibilities also include examining patients, taking medical histories, prescribing medications and ordering, performing and interpreting diagnostic tests. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A specialist level role that is a recognized subject matter expert in job area typically obtained through advanced education and work experience. Typically manages large projects or processes with limited oversight from manager, coaches, reviews and delegates work to lower level professionals, resolving difficult and often complex problems. Job Overview The Physician Advisor, Lead is a critical role that ensures physician support for high quality, compliant and efficient workflows related to utilization management. As a representative of Tufts Medicine and CMO(s), the role provides clinical direction and leadership to the organization, increasing the ability to produce optimal patient outcomes; ensuring quality, legal, ethical, regulatory, and reimbursement best practices. The role intends to further connect physicians with the end-to-end processes required for compliant and optimal reimbursement of care and to identify opportunities for increased efficiency and support for the required workflows. As a peer to clinical staff and hospital administration, the physician advisor is at the intersection of monitoring and intervening when practice patterns create disparities between pathway standards, severity of illness, patient and family rights, teamwork, or other issues regarding the stewardship of resources for patients, special populations, and the organization as a whole. Job Description Minimum Qualifications Doctorate from an accredited Medical or Osteopathic School 3 years of experience in a clinical practice OR certification as a physician advisor Prior experience in physician advisory Board Certified in applicable specialty Active medical staff privileges at health system obtained within ninety (90) days of hire Preferred Qualifications Prior leadership experience Duties and Responsibilities Provide overall direction and administrative leadership to the unit/department Provide Leadership on efficiency and productivity of utilization management functions in coordination with department operational leadership Lead and organize the ongoing evaluation of the utilization program against quality and utilization benchmarks and targets Identify opportunities for improvement, including organizing and managing costs of department processes Collaborate with health system leaders, including Quality Improvement, Analytics, Care Management, Finance, and other stake holders as needed Support department staff to assure quality, inter-rater reliability and standards are met in daily operations including resolution and communication of utilization management issues and concerns Collect data following established procedures and analyzes findings for purposes of continuous quality improvement and for internal and external reporting Provide medical staff education around utilization management principles and activities Oversee utilization management and criteria-based reviews of care, clinical appeals regarding medical necessity (including peer-to-peers), and the interaction with claims payment policies and processes Act as medical lead business and clinical liaison to health system providers and facilitate support for the effective execution of department programs Co-chair the utilization management committee Supervise and have direct responsibility for Physician Advisors, including accountability for yearly performance reviews, insuring quality control of work products, and development of applicable skillsets Achieve key financial and/or operational outcomes as determined by department leadership Establish systems and process that drive accountability for utilization management principles, including financial and/or operational outcomes Work effectively with cross company partners to execute divisional and departmental initiatives and day-to-day operations Act as an effective communication conduit horizontally and vertically throughout the organization Develop talent within the team, including acquiring, engaging, and retaining Staff, organize, and schedule the team to leverage maximum labor productivity Establish metrics that measure key business outcomes Translate organizational vision and strategies to department level and mobilize allocated resources to achieve profitable growth Effectively anticipate obstacles and barriers and work creatively to avoid or overcome them Physical Requirements Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc. This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending / descending stairs, and operate office equipment Frequently required to speak, hear, communicate, and exchange information Able to see and read computer displays, read fine print, and/or normal type size print and distinguish letters, numbers, and symbols Occasionally lift and/or move up to 25 pounds Skills & Abilities Ability to read and write in the English language; ability to understand and speak English fluently enough to be easily understood by patients, hospital personnel, physicians, and visitors Strong critical thinking skills and sound clinical background with a working knowledge of disease processes, anatomy and physiology, and treatment regimens Ability to analyze and interpret clinical information in the patient's medical record Excellent verbal and written communication skills with strong attention to detail and accuracy Aptitude to interact confidently and communicate effectively with physicians and other members of the clinical team Willingness to work collaboratively within a team Knowledge of Epic and CMS regulations High level computer literacy and efficiency with technology, including but not limited to, Microsoft Office Suite (including Word, Excel, Teams), Zoom, Epic, 3M360 Ability to use good judgment in an emergency situation Commitment to upholding and providing services in a manner that is congruent with Tufts Medicine's mission statement The salary range for this position is $135.00 - $165.00 hourly. Actual compensation will be determined during the selection process and is based on a variety of factors, including, but not limited to, relevant experience, education, internal equity, and academic rank. #J-18808-Ljbffr Tufts Corporate