Physician Advisor

Physician Advisor

Primary City/State: Virtual - Arizona

Category: Administrative Support

Shift: Day

Department: Case Management

Great care starts with great people. (Like you.)

At HonorHealth, you'll find something special. From humble beginnings in 1927 to one of Arizona's largest nonprofit healthcare systems, our culture is built on warmth and neighborly kindness. Behind every smile is a highly skilled professional with deep expertise and an unwavering dedication to what matters most — caring for the health and well-being of people and communities across the greater Phoenix area.

Responsibilities:

Job Summary The System Physician Advisor (PA) serves as a liaison between the hospital administration, physicians, payers and case management. The goals include patient class determination, ensuring proper utilization of resources, and delivery of quality patient care. The PA conducts clinical reviews on cases referred by case management staff and/or other health care professionals to meet regulatory requirements and in accordance with the hospitals objectives for assuring quality patient care and effective, efficient utilization of health care services. The PA meets with case management and health care team members to discuss selected cases and make recommendations for care, interacting with medical staff members and medical directors of third party payers to discuss the needs of patients and alternative levels of care. The PA acts as consultant to and resource for attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources. The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations. As a CDI physician advisor, the PA will act as a liaison between the CDI professionals, HIM, and the hospital's medical staff to facilitate accurate and complete documentation for coding and abstracting of clinical data, capture of severity, acuity and risk of mortality, in addition to DRG assignment. The PA will act as a liaison between the electronic health record (EHR) implementation teams and the medical staff ensuring that the system is optimized for effective physician use. The NPA helps facilitate training for the physicians. The PA must demonstrate interpersonal and communication skills and must be clear, concise and consistent in the message to all constituents. Essential Functions

• Medical Record Review: Conducts medical record review in cases in question for medical necessity of admission, need for continued hospital stay, adequacy of discharge planning and quality care management. Manages a current prospect list within the overall physician database. Contacts attending physicians and/or consultants as needed to seek clarification or additional information, documentation requirements, discuss alternate level of care options, minimize denials, relieve bed capacity constraints and expedite care across the continuum. Evaluates potential denials and discusses with attending or consulting physicians as requested. If indicated, advises case management to render letter of non-coverage in compliance with regulatory requirements.
• Case Management Support: Supports case management department staff as it relates to clinical decisions, escalation of patient care issues and management of long LOS patients. Assists case management with development and communication of physician profiles to achieve and attain best clinical practice. Reviews medical records of patients identified by care managers or as requested by the healthcare team in order to: Assists with level of care and length of stay management, assists with the denial management process, reviews and makes suggestions related to resource and service management, assists staff with the clinical review of patients, determines if professionally recognized standards of quality care are met. Provides feedback to attending and consulting physicians regarding level of care, length of stay, and quality issues. Seeks additional clinical information from the attending and consulting physicians. Recommends and requests additional, more complete, medical record documentation. Recommends next steps in coordination of care and evidence-based medicine indicators. Reviews cases that indicate a need for issuance of a hospital notice of non-coverage/Important Message from Medicare. Discusses the case with the attending physician and if additional clinical information is not available, discusses the process for issuance and appeal to the physician. Documents patient care reviews, decisions, and other pertinent information. Understands and uses vendor product criteria and other appropriate criteria. Documents response to case management referrals. Supports Care Management in a data-driven approach. Notifies the care manager of any conflict of interest in reviewing a particular patient record. Assists with identifying a physician to review such record. Acts as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate. Facilitates, mentors, and educates other physicians regarding payer requirements. Participates 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. Participates in patient rounds with the Healthcare Team as indicated. Identifies patients who are appropriate for transfer to LTACH facilities and works with physicians to facilitate referrals as needed. Provides guidance to ED physicians and ED Care Management regarding status issues and alternatives to acute care when acute care is not warranted. Works with Care Management and an interdisciplinary team to ensure appropriate continuity of care and to reduce readmissions.
• Contacts Attending Physicians: Makes face-to-face contacts and presentations to all loyal physicians and potential physician groups introducing referral services, new products and present product offerings. Provides input on appropriate education plans for physicians to ensure knowledge and understanding of case management guidelines/protocols. This education may include medical necessity criteria, avoidable day capture, quality improvement opportunities and denial management strategies. Assists case management with development and communication of physician profiles to achieve and attain best clinical practice.
• Conducts Peer to Peer negotiations with payers as indicated: Acts as liaison and coordinator with operations for the physician base and sets up tours, meetings, and conferences. Acts as liaison for physician improvement strategies. Reviews concurrent denials and intervenes with attending and/or consulting physicians and managed care medical directors, as needed, for reconsideration and denial avoidance. Works with case managers on this process to ensure proper resolution. Serves as liaison between medical staff and members of HIM and Denial Management department to encourage thorough, complete and timely documentation, coding accuracy and optimal reimbursement.
• Attends JOC as requested by Utilization Management or Managed Care: Works with Director, Management and staff to facilitate client profiles, clinical service utilization and profitable revenue management.
• Serves as a consultant or participant as needed: Care conferences Process improvement committees Utilization management LOS joint committees Resource Utilization improvement efforts
• Supports compliance related to consistency of technical and professional: Recovery Audit Contractor (RAC) reviews.
• Performs other duties as assigned

Education

• M.D. or D.O. Board Certified Physician with a special interest in Utilization Management & Quality Improvement in - Required
• Graduates of an accredited medical school - Required

Experience

• 5 years of recent experience in clinical practice - Required

Licenses and Certifications

• Physician ABMP - Amer Bd Of Med Phys-Cert - Preferred
• Physician MD - Physician - State Licensure - Preferred