Physician Advisor Director

Requirements

• 2-4 years of recent experience and expertise in Utilization Management and Clinical Quality Management and 5 years of direct clinical experience.
• Has knowledge of Pay for Performance/VBP initiatives and incentives.
• A high level of interpersonal skills to allow effective communications and interaction with a wide variety of hospital personnel, physicians, and the general public
• Documented interest and experience in the education and quality improvement needs for the various service lines under his/her responsibility
• Familiarity with Clinical Documentation requirements and working knowledge of Centers for Medicare and Medicaid services, rules and regulations.
• Principal Duties and Responsibilities:
• Works productively with all department leaders to ensure that clinical care is consistent with current scientific advances and best evidence existing in published clinical literature or as established by recognized professional associations.
• Provides input at least annually for strategic and operational planning purposes and an assessment of Case Management, UR and DC/TOC efficiency and effectiveness.
• Makes recommendations to the Hospital's administration regarding the use of hospital personnel, any necessary equipment, and general quality standards of patient care.
• Provides leadership and support to develop and maintain effective UM coverage at all points of entry to the Hospital (POE's). POE process should be inclusive of UR appropriateness, admission avoidance, discharge planning and internal/external resource utilization.
• Supports effort to formalize PA, CM, and Revenue Cycle department operational integration (weekly or bi-weekly) to ensure claims are paid, and that medical necessity issues are addressed concurrently.
• Review denials for patients in the hospital or recently discharged and conduct peer-to-peer consultations with attending physicians as appropriate.
• Review requests for accommodation codes, reviews daily report for status change for Medicare patients and other requests for status and makes recommendations/decisions based on consultations with attending physician.
• Reviews all denials and is responsible for the administration of the appeals process, including completion of appeal letters, and communication & education of medical staff.
• Provide oversight of the development and approval of all operating policies and procedures for Physician Advisor services in conjunction with the responsible Administrator.
• Represents, or appoints designee to represent the hospital's interests to external organizations concerned with denial management/Medicare or insurance providers.
• Collaborates with PA peers/mentors on an inter-rater reliability (IRR) process to capture standardized policies and procedures that can be used to support overall program strategy and utilization management approach.
• Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, and alternative levels of care
• Educates specific medical staff departments (Hospitalists, Surgery, Residents, etc.) at department meetings regarding correct disease reporting, ICD code assignment, capture

Benefits

Additional Information

Under the co-direction of the Executive Director of Reimbursement, Chief Medical Information Officer, and Associate Chief Medical Officer, the Physician Advisor Director provides leadership to a team of associate Physician Advisors that supports case management, social work, coding team, utilization review, population health, and other clinical members to provide cost efficient, high quality inpatient and observation care at GBMC Hospital. This management includes level of care reviews, all denial reviews and appeals management for all hospital patients. The Physician Advisor Director is responsible for clinical direction of these services and shall be responsible for the development, implementation and oversight of policies and procedures as they apply to the provision of assigned services. The Physician Advisor Director is a 0.75 to 1.0 FTE and will report directly to the Associate Chief Medical Officer. Education: Graduate of an accredited medical program. Additional education in utilization and quality management through continuing medical education program and self-study Licensures/Certifications: Licensed as a physician in the State of Maryland Board Certified by the American Board of Internal Medicine, or other certifying Board as deemed appropriate by Chief Executive Officer.

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