Position Summary
The Physician Advisor PA will act as a liaison between the medical staff, revenue cycle physician leadership teams, and hospital administration teams, ensuring that the system is optimized for regulatory compliance, medical necessity, and efficient utilization of healthcare services. The PA conducts clinical reviews on cases in accordance with the hospitals objectives for assuring quality patient care and effective clinical documentation.
Responsibilities
• The PA meets with care management and healthcare 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 providers 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. • Acts as second-level reviewer through the review of medical records of patients identified by care managers or as requested by the healthcare or administration teams. • Assist with the patient status determination level of care and length of stay management. • Assist with the denial management process. • Review and make suggestions related to resource and service management. • Assist staff with the clinical review of patients. • Determine if professionally recognized standards of quality care are met. • Optimization of the observation rates and observation length of stay. • Provides feedback to providers regarding level of care, length of stay, and quality issues. • Seeks additional clinical information from the providers. • 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 in patients electronic health record (HER) care reviews decisions and other pertinent information. • Understands and uses InterQual 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 patients 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 providers 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 lower levels of care such as skilled nursing facilities, SNF, palliative care, long-term care, assisted living, LTACH facilities, and hospice. • Works with physicians to facilitate referrals as needed.
• Provides guidance to emergency department (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. • Provides education to providers related to regulatory requirements, appropriate utilization, alternative levels of care, community resources, and end of life care. • Works with physicians to facilitate referrals to the continuum of care.
• Assists physicians with end of life care, palliative care, and hospice care consultations when appropriate. • Provides education to physicians and other clinicians regarding providing the appropriate level of care. • Identifies clinical quality patient safety, satisfaction, and efficiency issues leading to suboptimal care. • Takes appropriate action to resolve. • Promotes and educates healthcare team on a team approach to patient care. • Promotes coordination, communication, and collaboration among all team members. • Supports the organization in clinical documentation and quality improvement efforts requiring physician input and/or involvement.
• Educates individual hospital staff physicians about ICD 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. • Works with the EHR team and quality officers and performance improvement to ensure the system appropriately supports the physicians ability to provide best practice medicine by creating logical processes and providing the necessary order sets and practice guidelines. • Participates in physician and graduate medical education and outreach efforts. • Works in collaboration with the ITCE team to be sure all necessary providers are trained and training is appropriate for the providers. • Participates as part of the physician advisory council to assist IT CE with clinical decisions for the HER. • Assists with order set development review and implementation to coordinate quality, efficiency, and utilization of the order sets. • Understands current insurance regulations and quality metrics.
Qualifications
Education and Training
• Medical Doctorate degree required. • Must have completed training in an accredited residency. • Additional education in quality and utilization management through continuing medical education programs and self-study.
Licensure and Certification
• Maintains active State of Florida Medical Doctor license. • Certification as Physician Advisor. This can be obtained in the first 6 months after hire.
Experience
• Minimum of three (3) years recent experience in clinical practice.
Other Related Functions
• Actively participates in Hospital committees to develop protocols related to evidence-based medicine and supports optimal standards of care. • Presentations to Medical Staff Board Administration as needed. • Chairs or serves on the Utilization Management Committee. • Participates in the peer review process, makes suggestions on ways to improve this process. • Assists with the evaluation of the hospital utilization management program. • Maintains current knowledge of federal, state, and payer regulatory and contract requirements. • Attends continuing education sessions pertaining to utilization and quality management. • Assist in the management of denials and appeals. • Participates in the length of stay reduction initiatives. • Serve as a champion for care management and social work functions, transition of care, and multidisciplinary care teams.