The Physician Advisor is a key member of the healthcare organization's leadership team and is charged with meeting the organization's goals and objectives for assuring the effective, efficient utilization of health care services. The Physician Advisor is a physician serving the hospital through teaching, consulting, and advising the care management and utilization review departments and the hospital leadership. The Physician Advisor shall develop expertise on matters regarding physician practice patterns, over and under-utilization of resources, medical necessity, levels of care, care progression, denial management, compliance with governmental and private payer regulations, appropriate physician coding and documentation requirements. The Physician Advisor works closely with the medical staff leadership, the entire medical staff, all areas of resource management, case management, social services, discharge planning, and utilization management to develop and implement methods to optimize use of hospital services for all patients while also ensuring the quality of care provided. This includes working with hospital leadership in developing care management protocols with physicians and others to optimize length of hospital stay and efficient management of resources, insuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities.
MINIMUM QUALIFICATIONS AND REQUIREMENTS
Hold and maintain an unrestricted medical license in the state of New Jersey.
Board Certification (base specialty) recognized by ABMS or ABQAURP
Master Degree Preferred
Possess or acquires a solid foundation, knowledge, and/or experience in the areas of utilization management, quality improvement, and patient safety.
Possess a working knowledge of (Hospital) organization & case management operations and administrative standards and policies.
Strong computer skills and working knowledge of the EMR.
Familiarity with MCG/Interqual placement status criteria is preferred.
ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and ability required. Reasonable accommodations may be made for a qualified individual with disabilities to perform the essential functions.
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 cases that indicate a need for issuance of a hospital notice of non-coverage/Important Message from Medicare (HINN). Discuss the case with the attending physician and if additional clinical information is not available, coordinate the process with the Care Manager for issuance of HINNs
Understand and use MCG/InterQual and other appropriate criteria. Document response to case management referrals. Support Case Management in a data-driven approach
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 indicated
Educates individual hospital staff physicians about ICD-9 and ICD-10 and DRG coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records.