Physician Advisor
1 month ago
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Full Time
Job Summary: The Physician Advisor performs case reviews and provides guidance for medical necessity of care, assesses resource utilization, supports compliance standards, and improve clinical documentation processes in order to optimize use of services for all patients while ensuring quality of care.
Minimum Education: Commensurate education as appropriate to obtain Oklahoma State Medical License.
Licensure, Registration and/or Certification: An active and clear Oklahoma State Medical License. Member of the American College of Physician Advisors (ACPA) preferred. Health Care Quality & Management (HCQM) Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or Physician Advisor Sub-Specialty (CHCQM-PHYADV) certification by ABQAURP preferred.
Work Experience: Minimum of 3 years of experience in utilization management, case or resource management.
Knowledge, Skills and Abilities: Demonstrated knowledge of utilization management operations, quality improvement and patient safety initiatives. Current knowledge of federal, state, and payer regulatory and contract requirements. High level of interpersonal and communication skills necessary to interact effectively with internal and external stakeholders. Strong computer skills and working knowledge of the electronic medical records (EMR) system. Ability to build relationships with medical staff and health system leadership to obtain the collaboration necessary to achieve desired outcomes. Proven ability to analyze situations accurately to make reasoned decisions and adopt an effective course of action. Ability to drive results and produce outcomes.
Essential Functions and Responsibilities: Performs medical necessity reviews identified by utilization nurses including initial level of care, secondary and continued stay reviews; requesting additional medical record documentation to support placement status or medical necessity. Ensures the timely, accurate, and completion of medical records, including documentation of medical necessity and correct coding for services rendered, in compliance with Medical Staff Bylaws. Provides guidance and direction on length of stay benchmarks, utilization of resources, and denial management process; consults with physician and key stakeholders to resolve issues about length of stay, level of care, clinical documentation improvements, identified trends and other patient care standards. Works with payers to facilitate approvals and prevent denials when appropriate by participating in peer-to peer discussions; mentoring and educating other physicians regarding payer requirements. Collaborates with interdisciplinary team members regarding the technical component of services rendered including initial billings, follow-up reports, and appeals; assisting with regulatory audits and reviews, as needed. Tracks, analyzes, and reports on performance metrics and preserves documentation involving appeal and denial outcomes and other matters relating to patient care decisions. Attends meetings and participates in activities to develop and maintain protocols related to evidence-based medicine and to support optimal standards of care.
Decision Making: Independent judgment in making decisions from many diversified alternatives that are subject to general review in final stages only.
Working Relationships: Works directly with patients and/or customers. Works with internal and/or external customers via telephone or face to face interaction. Works with other healthcare professionals and staff. Works frequently with individuals at Director level or above.
Special Job Dimensions: None.
Supplemental Information: This document generally describes the essential functions of the job and the physical demands required to perform the job. This compilation of essential functions and physical demands is not all inclusive nor does it prohibit the assignment of additional duties.
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