Description
Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network.
General Overview
This job assures the most cost-effective, appropriate use of health care services for patients treated at Allegheny Health Network while correlating patient clinical information with both government and commercial payer utilized regulations and criteria regarding severity of illness, intensity of service, and the appropriateness of the setting for the administration of that care. The Physician Advisor is responsible for level of care reviews and peer-to-peer discussions with payers if denials do arise. The role requires significant collaboration with the hospital’s interdisciplinary care team including Physicians, Case Managers, UM nurses, and the hospital leadership team. The Physician Advisor is an integral part of the Utilization Management Committee and participates in hospital and enterprise-level quality and throughput initiatives. This position reports to the Senior Vice President of Care Continuum and Transitions and the Medical Director of Physician Advisors.
Essential Responsibilities
- The Physician Advisor works in concert with the admitting physician, Case Management, and other hospital personnel, to evaluate the medical necessity and appropriateness of: admission to the hospital, utilization of observation status and services for those patients, continued stay in the hospital, and ancillary services ordered. When appropriate, discuss the case with the attending physician regarding medical necessity.
- When requested, discuss the case with the insurance company medical director to obtain payer authorization or conduct a peer-to-peer discussion in cases of a denial.
- Provide medical expertise, advice, and support to the Case Management Department.
- Provide education to the medical staff regarding medical necessity and appropriateness of health care services.
- Provides ongoing education to residents/colleagues regarding observation status and case management.
- Assists with appeal letters and participates in data collection activities for utilization management.
- Receives daily report from Nursing Service (Bed Management) and Case Management on all observation cases.
- Reviews the status of observation cases, facilitates use of institutional processes and communicates with attending physicians and case managers regarding the patient's status.
- Conducts interdisciplinary rounds to drive quality and reduce length of stay in concert with case management, physicians, and the rest of the multidisciplinary team.
- Interacts regularly with coding and clinical documentation specialists.
- The Physician Advisor is required to be an active member of the Utilization Management Committee.
- Leads and reports data on case management and observation services on the bi-weekly Throughput Meeting.
- The Physician Advisor needs to be able to review and analyze metric reporting dashboards and implement action plans if not meeting goals.
Qualifications
Minimum
- 5 years of clinical practice experience in a hospital setting required.
- Board Certified in any Medical Subspecialty.
- PhD/MD Graduate of an accredited medical school with a Doctor of Medicine (MD) or Doctor of Osteopathy (DO) degree.
- Current PA MD licensure in good standing; current unrestricted DEA certificate.
Preferred
- Board Certified in Quality/Physician Advising.
- Physician Advisor experience in a clinical setting.
- Physician Advisor experience with cross-functional teams.
- Physician Advisor experience with large health system.
- Physician Advisor experience with integrated payer/provider network.