MD Physician Advisor - Utilization Management Cobb

The Physician Advisor reports to and is accountable to the Vice President Medical Affairs (VPMA) to impact quality, utilization, patient satisfaction and efficiency metrics through Performance Improvement and education initiatives that will enable the facility to achieve its stated goals. Working in collaboration with the VPMA(s) in the Well Star Health System (WHS), the Physician Advisor (PA) will be involved in the following areas:
Utilization Management:
The Physician Advisor (PA) will conduct clinical review on cases for commercial payers and medicare advantage plans that are referred by Care Coordination/Case Management staff and/or other health care professionals to assess for appropriateness of care; proper level of care in accordance with hospital objectives for assuring quality patient care and effective, efficient utilization of health care services, and to meet regulatory requirements.

Working as a peer to physicians and as a consultant to Care Management and administration, the PA intervenes when practice patterns or behaviors or documentation issues create disparity between pathway standards, intensity of service, severity of illness, patient and family rights, teamwork, or other issues regarding the stewardship of resources for individual patients, diagnostic populations, and the organization as a whole.

In the area of Readmissions, the Physician Advisor will help to lead the effort to reduce avoidable readmissions. The Physician Advisor will engage with Physicians, Advanced Practice Professionals, nursing and other ancillary personnel as well as administrative leaders as part of his/her role in Performance Improvement, Resource Utilization and ongoing education on imp8ortant trends in healthcare management. Quality Improvement:
In addition to the above duties, the PA will work with the VPMA and the Quality Director or Manager at the hospital on quality improvement initiatives to assist the hospital to achieve its annual goals.

The Physician Advisor (PA) will work closely with the Care Coordination/Care Management team to provide timely consultation and clinical expertise to ensure fiscally responsible and efficient utilization of resources. These duties will include but not be limited to areas such as concurrent assessment of the clinical situation, determination of medical necessity and appropriate level of care, real time feedback to physicians and case managers and all necessary follow-up with appropriate and clear communications of next actions to physicians;

care coordinators, social workers, nursing staff and other key people involved in caring for individual patients whose cases have been referred for consultation:

• a) Assist with level of care and length of stay management. This will include assessment of Inpatient vs. Outpatient Obs. Status;
  Compliance with 2 MN Rule, assistance with throughput initiatives and care transition issues.
• b) Lead Readmission reduction initiatives at the facility with the Chairperson of the Readmission PIC and in collaboration with the VPMA.
• c) Assist with denial management process on a concurrent basis if possible.
• d) Work closely with the Care Coordination Leadership to expedite case management issues and manage work queues.
• e) Review and make suggestions regarding resource and service management.
• f) Assist staff with clinical review of patients.
• g) Review clinical records for appropriate and accurate clinical documentation to ensure that medical necessity and level of care for services will be substantiated.
• h) Will work with the Clinical Documentation Excellence Specialists (i.e., CDS/CDI) to assist with physician queries for documentation or clinical criterion…