PHYSICIAN ADVISOR

Conducts clinical review on cases referred by case management staff and/or other health care professionals in accordance with the hospital’s objectives for ensuring quality patient care and effective, efficient utilization of health care services, and to meet regulatory requirements. Assist case management with length of stay reviews and facilitating discussion with the attending physician in cases where there is no progression in the plan of care, an ambiguous plan of care, or where there may be an ability to provide the plan of care at an alternate level.

Overview: The Physician Advisor acts as a liaison between the physicians, Clinical Resource Management and the hospital administration. The Physician Advisor works as part of a team and advises physicians on medical practices that are best practice regarding throughput and appropriate levels of care. The physician advisor is responsible for staying updated with the frequent changes in rules and regulations. 

Demonstrates excellent customer service performance in that his/her attitude and actions are always consistent with the standards contained in the Vision, Mission and Values of Covenant HealthCare.

Responsibilities:

Communicates with physicians, especially when difficult issues arise and have critical conversations concerning resource utilization and throughput.

Facilitate process of engaging hospital physicians to provide input on medical necessity and denial cases.

Provides feedback to attendings and consulting physicians regarding level of care, length of stay, and quality issues.

Seeks additional clinical information for the attending/consulting physicians. Recommends and requests additional, more complete, medical record documentation. Recommends next steps in coordination of care and evidence-based indicators.

Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, alternate levels of care and end of life care. Supports and educates physicians to facilitate referrals to the continuum of care.

Review and focus upon patients that have excessive LOS and/or high risk for readmissions based on screening criteria

Address unresolved consults/diagnostic delays

Engage with attending physicians with peer-to-peer dialogue when treatment paths are ambiguous

Assist with resolving Patient/Family/Physician conflict, esp. focus on plans/transitions of care

Perform peer-to-peer calls with Medical Directors at Skilled Nursing Facilities, Long-Term Acute Care Hospitals, and Home Health agencies to clarify complex treatment regimens

For high-risk cases, facilitate direct peer-to-peer communication for warm handoffs to Primary Care Providers and specialists

Participate in root-cause analyses on avoidable patient days and operational delays, presenting actionable findings to medical executive committees and hospital leadership

Regular participation in daily muti-disciplinary rounds on adult inpatient units

Assist case management with length of stay reviews and facilitating discussion with the attending physician in cases where there is no progression in the plan of care, an ambiguous plan of care, or where there may be an ability to provide the plan of care at an alternate level.

Conduct second level medical necessity reviews for all patient cases that do not meet first level screening criteria or do not have a documented expectation length of stay.

Provide recommendations on inpatient admissions, outpatient and observation services, or case not appropriate for hospital level services.

Review and/or sign condition code 44 (MOON form) cases.

Participate in Utilization Management Committee meetings and serves as a chair to the committee.

Use OPTUM’s proprietary logic and defined process to perform 2nd level case review.

Assist CRM staff with clinical review of patients.

Perform OPTUM’s AccURate reviews as needed and appropriate for commercial cases.

Conduct peer-to-peer discussion with commercial payer medical director for cases that have been denied concurrently.

Conducts clinical review on cases referred by case management staff and/or other health care professionals in accordance with the hospital’s objectives for ensuring quality patient care and effective, efficient utilization of health care services, and to meet regulatory requirements.

Meets with case management and healthcare team members to discuss selected cases and make recommendations for care.

Interacts with medical staff members and medical directors of third-party payers to discuss the patient needs and alternative levels of care.

Acts as consultant and resource to attending physician regarding their decisions relative to appropriateness of hospitalization, continual stay, and use of resources.

Acts as consultant and resource to the medical staff regarding federal and state utilization and quality regulations.

Acts as a liaison in collaboration with the Denial Nurse with payers to facilitate approvals and prevent denials or carved out days with appropriate. Facilitates, mentors and educates other physicians regarding payer requirements.

Participates/facilitates the Long Length of Stay Meeting to review of Long Length of stay patients in conjunction with the CRM Director.

Work side by side with case managers, giving direction and education on patient process flow and provide support to internal department in order to foster trust within medical staff.

Offer guidelines about level of care, length of stay, readmissions and other utilization issues.

Keep abreast of all pertinent federal, state regulations, laws, and policies and facilitate dissemination of relevant information to hospital clinical staff as appropriate.

Qualifications:

EDUCATION/EXPERIENCE REQUIREMENTS

Graduate of an accredited medical school required.

Current State of Michigan medical license required.

Minimum of 3 years of experience in a hospital-based practice setting.

 

KNOWLEDGE/SKILLS/ABILITIES

Demonstrated ability to build rapport with medical staff and hospital leadership.

Ability to work for extended hours and also handle pressure.

Must be up to date on latest technologies and medical procedures.

Strong computer skills and working knowledge of EMR’s.

Demonstrated ability to deliver high quality, cost-effective, efficient patient care services.

Utilization Management experience.

Have familiarity with current medical literature, healthcare reimbursement issues (i.e. medical necessity, levels of care, coding), MCG/Inter Qual screening criteria, Medicare/Medicaid compliance, and medical staff structure, policies and procedures.

 

WORKING CONDITIONS/PHYSICAL REQUIREMENTS

Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.

Constant sitting, talking, or hearing.

Frequent standing, walking, lifting, carrying, and use of hands to finger, handle and feel.

Frequent lift 0-25 lbs.

Frequent near, far, depth perception, color vision, and field of vision.

Occasional push, pull, balance, climbing, stooping, crawling, kneeling, crouching, taste or smell.

 

Occasional lift 26-50 lbs.