Physician Advisor

The Physician Advisor plays a critical role in promoting evidence-based standards of medical care while maintaining appropriate utilization of hospital resources for our Mercy Gilbert and Chandler Regional Medical Center locations. The position's emphasis is on facilitating communication between the Department of Care Coordination, Medical Staff, Nursing Staff, and Administration regarding systems-based practice, regulatory and quality considerations in the delivery of medical care. Performs the duties of this role according to the organizational objectives, hospital policies, standards of practice and Federal and State regulations.

Roles and Responsibilities 

• Mitigate denials for payment from insurance payers by providing valid and effective secondary medical necessity reviews. Review and report performance measures and make recommendations to Departments and the Medical Executive Committee regarding opportunities for improvement of patient care, resource utilization, billing compliance and reduction of claims denials.
• Provide compliance element for Centers for Medicare and Medicaid Services (CMS)Conditions of Participation (COP) by performing secondary medical necessity reviews.
• Provide a more cost-effective delivery of secondary medical necessity reviews than what is currently provided by outside contracted services (Executive Health Resources (EHR).
• Champion good stewardship of resources.

Inpatient Facilities

• Align and collaborate with the facility leadership.
• Understand and appreciate unique elements of facility history and culture in order to effectively execute/implement job duties and functions.
• Act as a resource for work teams that align with facility utilization initiatives (i.e. leverage the leadership influence of Physician Advisor by mobilizing other physicians and staff). Provide education to medical staff colleagues regarding best practices, the utilization review process, regulatory issues, use of clinical guidelines, and appropriate levels of care.
• Optimize revenue capture by providing oversight for appropriate status determinations.
• Provide compliance element for CMS Conditions of Participation by active involvement in the facility utilization management processes.
• Optimize cost of care by providing oversight for appropriate level of care determinations. Serve as resource for Care Coordination by determining the appropriateness of the referrals, applying professional judgment in the context of patientrelated variables, and consulting with attending physicians, residents, and other health professionals as needed in order to clarify issues regarding appropriateness of level of care, care alternatives, and resource utilization.

Inpatient Facility Care Coordination

• Provide advisory support to staff in their care transition challenges. Advocate for and facilitate quality patient care by identifying systems barriers, practice variances or resource challenges that impede, delay or interfere with efficient, effective and appropriate health care delivery.
• Engage physician staff in discussions concerning transitions of care.
• Engage physician staff in discussions concerning utilization of resources. Facilitate the timely prospective, concurrent, or retrospective review of resource use in referred cases, with the objective of optimizing length of stay and reducing avoidable days and claim denials.
• Influence physician practices to optimize documentation for medical necessity staff.
• Complete medical necessity reviews for status determinations and levels of care as tasked by care coordination staff during standard business days / hours.
• Provide medical necessity documentation for status determination changes as encountered on facility patient care units.

Qualifications

Minimum Qualifications Required

Education

• Medical degree or DO degree with active medical license.

Experience

• Minimum of five years clinical practice experience.
• Active member in good standing of Hospital's medical staff and participating member of various medical committees.

Licensure

• Licensed to practice medicine without restrictions in the State where performing Physician Advisor duties; MD AZ or DO AZ.

Special Skills

• Strong clinical judgment and technical abilities.
• Strong collaboration skills with other physicians.
• Excellent interpersonal and communication skills.

Training

• Knowledgeable in basic principles of utilization management and quality assessment.