Description
Roles and Responsibilities Overview
The Physician Advisor is a full-time administrative physician role serving CHRISTUS St. Michael hospital and its affiliates through teaching, consulting, and advising both the Care Management Department and the medical staff on matters regarding physician practice patterns, documentation, over- and under-utilization of resources, medical necessity, compliance rules and regulations, collaboration and relationships with payers, and the community.
Reporting Relationship
The PA reports directly to the Chief Medical Officer of St. Michael hospital- Texarkana
Professional Qualifications
The Physician Advisor-Care Management and Clinical Documentation Improvement role should be staffed by a physician with the following qualifications:
- 5 years of clinical experience
- Licensed physician in state of residence
- Board certified in a clinical specialty
- Certified by the American Board of Quality Assurance and Utilization Review Physicians, Inc (ABQUARP) - preferred
- Experienced in clinical practice with an understanding of utilization review
- ·Served on or chaired an Utilization Management Committee
- ·Demonstrated cost-efficient practice
Physician Advisor - Care Management & CDI Duties and Responsibilities
Utilization Management Plan: 20%
- In collaboration with the Director of CM, lead the Utilization Review Committee
- Conduct secondary status reviews for appropriate level of care determination
- Conduct peer-to-peer consults with the payor medical directors for the denied cases, to resolve medical necessity issues prior to claims submission.
- In collaboration with the CMO and Director of CM, monitor key metrics for UM and participate in action steps to achieve targets. Metrics include (but not limited to):
- Denial trends, appeals & recoveries
- Length of stay- inpatient and observation
- Condition Code 44
Physician & Staff Education: 15%
- Provide education to physicians and other clinicians related to regulatory requirements, appropriate billing status and utilization of alternate levels of care, community resources, and end of life care.
- Work with physicians to facilitate referrals to the continuum of care
- Facilitate, mentor, and educate other physicians regarding payer requirements
- Provide mentoring/coaching to UR Case Managers to increase knowledge in care progression
- Educate physicians on the benefits and importance of a clinical documentation program and how to work with CDI specialists