Physician Advisor and CMIO Role

Physician Advisor (PA-Utilization Management)

The Physician Advisor (PA-Utilization Management) serves as the physician leader in matters relating to patient care. The PA will partner to reduce length of stay, ensure appropriate use of level of care determinations (inpatient, observation, outpatient, and other classifications as identified), support documentation and coding improvements and ensure organizational compliance in all areas. PAs facilitate communication across the patient care continuum (including the Interdisciplinary and Post-Acute teams, Payors, Administration and Revenue Cycle) to improve utilization management, sustain quality goals, and act as a consultant to physicians, administration, and case management to assure appropriate resource usage, document medical necessity, and comply with Federal and State regulations/quality initiatives. Reports to the System Medical Director of Utilization.

This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at Ochsner's discretion.

Training, Certification and Skills

• Member of (1) American College of Physician Advisors (ACPA) or (2) Board Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or (3) Physician Advisor Sub-Specialty Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or (4) commitment to apply for such certifications
• Demonstrated ability to build rapport with medical staff and hospital leadership.
• Comfortable having challenging conversations
• Strong computer skills and working knowledge of EMRs
• Demonstrated ability to deliver high quality, cost-effective, efficient patient care services
• Utilization Management experience (preferred)
• Familiarity with: Current medical literature, Healthcare reimbursement issues (e.g., medical necessity, levels of care, coding), MCG / InterQual screening criteria, Medicare / Medicaid compliance, medical staff structure, policies and procedures
• Physician Advisors will have access to the required reports and data to make decisions, and to all pertinent federal, state regulations, laws, and policies and facilitate dissemination of relevant information to hospital clinical staff as appropriate.

Essential Position Duties

Create and Sustain Partnerships

• Partner and collaborate with stakeholders in the support of appropriate management of patient care activities; Intercede on issues as needed to gain appropriate resolution (especially via direct with Provider communication; includes Case Managers, Coding, Revenue Cycle, Insurance Companies)
• Respond 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.
• Work with physicians on concurrent appeals (peer to peers)-discussions, appeals and denials
• Serve as an education resource to clinical and non-clinical personnel regarding medical necessity and regulations. (to include administration, providers, and operations teams)
• Work side by side with case managers, giving direction and education on patient process flow and provide support to foster trust within medical staff

Manage Patient Flow

• Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews
• Assist with length of stay management and utilization of resources
• Assist with the denial management process
• Review medical records of patients identified by case managers or as requested by stakeholders to perform quality and utilization oversight
• Provide regular feedback to physicians and all other stake holders regarding level of care, length of stay, and potential quality issues
• Recommend and request additional complete medical record documentation to support placement status or medical necessity
• Provide direction and support for issuance of a hospital notice of non-coverage/Important Message from Medicare (HINN).
• Understand and use MCG/InterQual and other appropriate criteria. Document response to case management referrals. Support Case Management in a data-driven approach
• Facilitate pre-payment reviews and/or participating in recovery audit contractor reviews
• Assist Hospital Administration in appeals process for retrospective denials
• Assist Hospital Administration and the Medical Staff in connection with any regulatory audits, investigation, survey, or other review of the Departments
• Ensure consistency of utilization review services, quality control, and patient safety
• Act as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate by participating in Peer-to-Peer discussions and reviews
• Participate in review of long stay patients, in conjunction with the Care Management Leadership, Care Management team, and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care
• Participate in Interdisciplinary Rounds (IDT) with the Healthcare Team as requested
• Provide guidance to ED physicians and ED Case Management regarding status issues and alternatives to acute care when acute care is not warranted
• Participate in all organizational efforts to improve quality performance metrics including but not limited to inappropriate readmissions, length of stay and observation initiatives
• Provide recommendations on inpatient admissions, outpatient and observation services, or case not appropriate for hospital level services
• Review and / or sign condition code 44 cases
• Identify and assist in removing barriers to discharge
• Provide written summary of activities including, but not limited to: recommendations for patient status, evidenced based support for decision-making, overview of discussions with physicians, plan of care for patient, next steps for interdisciplinary team (if appropriate), and appeal letter.

Serve as Improvement Champion

• Participate in and recommend Quality Improvement Initiatives relating to documentation improvement and patient placement
• Lead coaching of physicians and new residents on information related to, but not limited to:
• Documentation quality and standards
• Level of care status
• Utilization standards
• Participate/Co-Lead UM Committee effort at the hospital level

Education

• Participate in ongoing training and education related to the Physician Advisor role and responsibilities including topics related to Utilization Management, Care Management and other related areas as requested
• Identify & support education needs of the medical staff with regard to documentation, placement and utilization of resources

Other duties as assigned

• Occasionally, other duties may be assigned that relate to the PA's competencies

Performance and Reporting

The physician advisor will report to the Vice President of Medical Affairs. Performance of the physician advisor will be evaluated on metrics relating to

• Volume of work activity (esp: physician to physician interactions)
• Quality of interaction (e.g.: how it is perceived by the medical staff, other team members)
• Utilization process metrics (e.g.: avoidable days, conversions)
• Hospital throughput metrics
• Appropriate compensating metrics (e.g.: early readmissions)

The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time.

Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.

Complies with the Ochsner Health System Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns.

Ochsner is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.