St. Mary's Health Care System (SMHCS) has an excellent full-time employment opportunity for a Board Certified Acute Care Utilization Review Physician Advisor located in Athens, Georgia.
Through a dyad leadership structure, the Physician Advisor develops and educates providers and other clinicians on matters related to medical necessity and associated clinical documentation, level of care progression, and denials management. This work is done in collaboration with the case management (CM) and health information management (HIM) department leaders, and other key members of those departments, to develop and implement methods and strategies to optimize the use of hospital services and coding. Also works with leaders and key stakeholders involved in the revenue cycle and payer strategies, to reduce denials and protect reimbursement.
Essential functions of this role include:
Conducts clinical reviews on cases referred by CM staff and or other healthcare professionals to meet regulatory requirements in accordance with the hospital objectives for assuring quality patient care and effective, efficient utilization of health care services.
Acts as consultant to and resource for attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources.
Serves as a resource for the medical staff regarding federal and state utilization and quality regulations.
Responsible for establishing, maintaining, and strengthening the relationship with key stakeholders, including providers, senior leaders, department leaders and colleagues, to appropriately optimize the use of the physician advisor services.
As requested, acts as a liaison between the health information management department's clinical documentation improvement professionals and the hospitals medical staff to facilitate accurate and complete documentation for coding and abstracting of clinical data, capture of severity, acuity, and risk for mortality, in addition to DRG assignment.
Work closely with the medical staff and all utilization management (UM) personnel, to develop and implement methods and strategies to optimize the use of hospital services. This includes UM processes that ensure patients are in the appropriate level of care with supporting documentation of regulatory compliance and accurate coding.
Participates in third party payer meetings, as requested, and offers feedback for third party payer contract management services, as requested.
Meets with interprofessional team members to discuss the needs of patients and alternative levels of care.
Performs denials management related services, including verbal and written appeals, with medical directors of third-party payers.
Proponent and champion for organizational standardization and consistency in order to develop a fully integrated delivery system that aligns with St. Mary's Mission, Vision and Values.
Provides clinical direction for development and implementation of chronic condition care management programs, including integration of and compliance with payor mandated procedures, coordination of referral processes, and comparison to benchmarks of all utilization data and timely reporting of same to staff and management.
Provides administrative physician leadership for certain provider support services, including maintenance of timely physician and non-physician payor and facility credentialing, and coordination of the clinical aspects of professional liability issues.
Trinity Health is one of the largest multi-institutional Catholic health care delivery systems in the nation. We serve people and communities in 22 states from coast to coast with more than 90 hospitals and 100 continuing care facilities – including home care, hospice, PACE and senior living facilities and programs that provide nearly two and a half million visits annually. Trinity Health employs more than 133,000 colleagues, including 7,800 employed physicians and clinicians. Our mission: We, Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities. We support this mission by living our core values of Reverence, Commitment to Those Who are Poor, Justice, Stewardship, and Integrity. Committed to recruiting talented physicians, we are looking for physicians who share our values and want to help us fulfill the health care needs of the communities we serve. At Trinity Health, we value the physician relationship and focus on partnering with our physicians. Whether you are a practicing physician looking to relocate or a medical resident, we offer opportunities with the flexibility to fit your individual nee...ds. If you would like to be part of Trinity Health, we encourage you to explore this opportunity at www.trinity-health.org