Description
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 insurance information (criteria) regarding severity of illness, intensity of service and the appropriateness of the setting for the administration of that care. He/She communicates with and provides clinical information to third party administrator physicians for the purpose of securing payment authorization. Collaborates with physicians and other hospital personnel, including Case Management and the Clinical Resource Management Committee, in order to integrate and manage this care. This position reports into the hospital Chief Medical Officer with a matrix report to the Director of Physician Advisors.
RESPONSIBILITIES
- Physician Advisor - AHN.
- 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 case with attending physician regarding medical necessity.
- When requested, discuss case with insurance company physician administrator for the purpose of obtaining payer authorization.
- 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 colleagues regarding observation status and case management.
- Assist with appeals of denials and participates in data collection activities for resource utilization management.
- Receives daily report form 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 status of the patient.
- Assists with admission, treatment and discharge orders in coordination with the attending physician.
- Conducts interdisciplinary rounds to drive quality and reduce length of stay.
- Interacts regularly with coding and clinical documentation specialists.
- The Physician Advisor would be an active member of the Clinical Resource Management Committee.
- Participates in Payer contract reviews to determine criteria set forth to avoid unnecessary denials.
- Reports data on case management and observation services to the Committee.
QUALIFICATIONS
Minimum
- Doctorate in Medicine, MD or DO.
- 5 years clinical practice experience in a hospital setting required.
Preferred
- Physician Advisor experience in clinical setting.
- Physician Advisor experience with cross-functional teams.
- Physician Advisor experience with large health system.
- Physician Advisor experience with integrated payer / provider network.
