Physician Advisor bei Ephraim McDowell Regional Medical Center, Inc.

JOB SUMMARY:

The Physician Advisor  conducts clinical case reviews referred by case management staff and/or other health care professionals to meet regulatory requirements and in accordance with the hospital’s objectives for assuring quality patient care and effective and efficient utilization of health care services. This individual meets with case management and health care team members to discuss selected cases and make recommendations for care as well as interacting with medical staff members and medical directors of third-party payers to discuss the needs of patients and alternative levels of care. The PA performs denials management and prevention in accordance with the organization’s goals and expectations. This individual reviews cases for clinical validation, performs peer-to-peer discussions and participates in appeal letter writing. The PA acts as a consultant to, and resource for, attending physicians regarding their decisions relative to appropriateness of hospitalization, clinical documentation, continued inpatient stay, and use of healthcare resources. The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations. The PA helps facilitate training for physicians. The PA must demonstrate interpersonal and communication skills and must be clear, concise and consistent in the message to all constituents. Exhibits the F.I.R.S.T. values (Friendliness, Innovation, Respect, Service and Trust).

ESSENTIAL FUNCTIONS, DUTIES AND RESPONSIBILITIES:

• Utilization Review Committee

1. Co-Lead the Utilization Review Committee with Facility representatives. 
2. At each meeting, report on findings of pertinent reviews completed by Provider and activities since the previous meeting. Other metrics as identified by the UR Committee. 
3. Report Utilization Review Committee findings to MEC
4. Work within the parameters of the Utilization Review Committee as defined by Medicare Conditions of Participation (42 CFR 482.30) and the UR Plan. 

• Concurrent Admission Review Includes, but shall not limited to: 

1. Review of medical records to determine admission status appropriateness using medical judgment when the documentation in the record does not support the ordered status as determined by MCG or other evidence based criteria 
2. Provide support and guidance regarding the appeals process to ensure both contractual and federal rule compliance. 
3. Uses medical judgment and evidence based practice research to determine appropriateness of status in collaboration with the treating physician. 
4. Consultation with the attending physician for documentation and additional clinical information, when needed. 
5. Provide education to the attending provider when documentation is not sufficient to support the status ordered. 
6. Reviews medical records and documents decisions within 3 hours of referral. 
7. Documents decision in designated area as directed by Facility. 

• Continued Stay Review Includes, but shall not be limited to: 

1. Review of medical records for continued stay appropriateness and/or resource utilization when the documentation in the record does not support the need for continued stay and/or resource utilization is high. 
2. Looks for technical elements required by payor and justification of extended stay and/or resource usage. 
3. Utilizes medical judgment and evidence based practice research to determine appropriateness of continued stay and resource utilization in collaboration with the treating physician. 
4. Consultations with the attending physician for documentation and/or additional clinical information, when needed. 
5. Review of medical records within 3 hours of referral 

• Concurrent Admission Denials Includes, but shall not be limited to:

1. Review of medical records when a payor disagrees with the status ordered by the provider while the patient is still in-house or prior to claim submission. 
2. Looks for technical elements required by payor 
3. Utilizes medical judgment and evidence based practice research to determine appropriateness of denial 
4. Works collaboratively with attending provider to craft justification for appeal of level of care, length of stay, and/or any other denial rationale 
5. Provide education to providers regarding missing elements that drove decision to not appeal specific claims. 
6. Performs Peer to Peer discussions within scheduled timeframe for inpatient medical necessity denials and any post acute denials for SNF, IRF, or LTACH as directed by UR and/or case management team members 

• Billed Claim Denials

1. When requested by Facility, prepares and writes all medical necessity appeals  
2. Makes recommendation to appeal or not appeal within 7 days of referral. 

• Clinical Documentation Advisor includes,,but shall not be limited to: 

1. Serve as physician champion of clinical documentation improvement efforts at the Facility
2. Provide and/or facilitate education to practitioners on clinical documentation requirements and coding issues pertaining to publicly reported performance data, accurate complication assessments, recovery audit practices, risk adjustment, compliance security,,quality improvement, (MS or APR)-DRG assignment and clinical validation of high risk diagnoses 
3. Encourage and assist physicians to obtain documentation training,,as needed, from the Clinical Documentation Improvement staff 
4. Mentor physicians with documentation deficiencies identified through audit or review to improve the quality of his/her documentation 
5. Educate physicians so that they understand industry changes related to coding and documentation requirements 
6. Communicate with physicians regarding documentation challenges and opportunities at both the individual physician and full Medical Staff level 
7. Serves as a resource for clinical documentation improvement staff,,coders,,and quality staff for clinically complex cases 

• Medical Necessity Education Includes, but shall not be limited to: 

1. Education of new-hire physicians on documentation requirements to support medical necessity from both a commercial and governmental payor perspective. 
1. Contractual Obligations (Commercial Payors) 
2. Rule/Statute Obligations (Governmental Payors)
2. Provide continued education as needed to further physician education and improvement. 
   

• Physician Advisor Education:

1. Provider is responsible to stay up-to-date on all new and changing regulatory and contractual obligations that affect the Physician Advisor role in the Facility. This includes, but shall not be limited to, participation in conference calls, webinars, in-person educational offerings, and/or professional organizations.

WORKING CONDITIONS, HAZARDS AND PHYSICAL EFFORT:

The position is primarily performed in an office environment, with the majority of time spent working at a computer workstation and on the telephone. Work involves extended periods of sitting, typing, and viewing a computer screen. Occasional standing, walking, and reaching may be required. The role requires clear and professional verbal communication over the phone, as well as accurate written documentation.Minimal lifting of office supplies or files (generally less than 20 pounds) may occasionally be required.

CONTACTS WITH OTHERS:

Actively participates in daily interdisciplinary collaboration with the case management team, including case managers, social workers, and utilization review staff, to thoroughly review and address care plans, medical necessity, and discharge coordination. In addition, engages in ongoing communication with attending providers to support the delivery of safe, effective, and timely care. Collaborates with third-party payors to complete peer-to-peer responsibilities and ensure appropriate authorization and coverage for services. Works closely with other associates, support personnel, and external partners as needed to promote continuity of care, optimize patient outcomes, and achieve overall success in fulfilling the responsibilities of the role.

EQUIPMENT USED/SPECIAL SKILLS REQUIRED:

Strong computer skills with working knowledge of EMR, familiarity with MCG criteria. Strong analytical, problem-solving, and decision-making skills