The Physician Advisor works closely with the medical staff leadership, the entire medical staff, including resident physician house staff, all areas of resource management, case management, social services, discharge planning, and utilization management to develop and implement methods to optimize use of hospital services for all patients while also ensuring the quality of care provided. This includes working with hospital leadership in developing care management protocols with physicians and others to optimize length of hospital stay and efficient management of resources, ensuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities.

Typical Duties

General functions

• * Provides one-on-one provider education, when necessary, on a wide array of topics including quality, utilization review, and documentation improvement.

• * Works closely with the Director of Inpatient Utilization and Case Management to provide oversight to utilization management professional and support staff to appropriateness of patient specific plans, improve denial rates, avoidable days and inefficient use of resources.

• * Works closely with the Director of Inpatient Care Coordination and care coordination leadership and oversight to improve discharge planning, throughput, length of stay, readmission rates and care transitions.

• * Works closely with the Clinical Documentation Improvement Manager to improve clinical documentation to reflect quality of care of care given and improve reimbursement.

• * Participates as a team member on other committees or subcommittees at the discretion and/or absence of the Medical Director of Utilization Management and Physician Advisory Services (Medical Director).

• * Facilitates strong working relationship between providers, nursing, clinical documentation specialists, case managers, utilization review staff, coding, and the management team.

• * Collaborates with IT Department with order set development, review, and implementation to coordinate quality, efficiency, and utilization of order sets.

• * Collaborates with the Health Information Management, Revenue Cycle team and clinical leaders to develop to optimize documentation quality and reimbursement.

• * Reviews the utilization of resources and objectively measure the outcomes for inpatient and observation stays and making recommendations.
• * Reviews cases referred by the denials team and cases under dispute with third party payers and presents the hospital's case to third party payer Medical Director or Peer Review Board, to overturn denials and receive payment.

• * Maintains an active clinical workload of at least 50%.

UM & Care Coordination Functions

• * Reviews medical records of patients identified by Clinical Case Managers or as requested by the healthcare team and making recommendations.

• * Understands and use of decision support tools such as MCG/InterQual and other appropriate criteria. Documents response to case management referrals and support Case Management in a data-driven approach.

• * Participates in Daily Interdisciplinary Rounds (IDR) with the Healthcare Team, structured Post IDR meeting and Long Stay meeting with Care Coordination leadership.

• * Performs medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews making suggestions on resources use and service management.

• * Identifies barriers to timely discharge and assists with developing solutions to remove those barriers in collaboration with care coordination team and health care team.

• * Provides regular feedback to physicians regarding level of care, length of stay, and potential quality issues, including request of additional and complete medical record to support placement status or medical necessity.

• * Provides guidance to ED physicians and ED Case Management regarding status issues and alternatives to acute care when acute care is not warranted.

• * Reviews cases recommended for issuance of a hospital notice of noncoverage or Important Message from Medicare (HINN) and coordinate the process with the Case Manager for issuance of HINNs.

• * Assists in clinical reviews related to billing; including initial billings, follow-up reports, and appeals in cases of retrospective denials and recovery audit contractor reviews.

• * Participates in regulatory audits, investigation, survey, or other relevant reviews of the Departments.

• * Acts as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate by participating in Peer-to-Peer discussions and reviews.

• * Facilitates, mentors, and educates other physicians regarding payor requirements.

• * Participates in all organizational efforts to reduce inappropriate readmissions.

Clinical Documentation Improvement functions

• * Provides education to medical staff and house staff on new clinical practice guidelines, protocols, research evidence and regulatory requirements including, but not limited to, ICD, meaningful use, Centers for Medicare & Medicaid Services (CMS), Joint Commission and compliance.

• * Educates specific medical staff departments (e.g., Internal Medicine, Surgery, Family Practice, etc.) at departmental meetings about ICD and DRG coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records.

• * Evaluates of Clinical Documentation Improvement (CDI) metrics by Physician performance profiling, physician E&M payment and pay for performance, appropriate hospital reimbursement for patient care.

• * Describes ways to provide improved health record documentation that specifically affect ICD code assignment capture of severity, acuity, risk of mortality, and DRG assignment.

• * Develop structure and implement a CDI integrity program, suitable to CCH clinical staff and Coding team.

• * Participates in screening for medical necessity, ensuring the appropriate level of care and physicians' appropriate response to clinical queries using the health systems established guidelines.

• * Monitor physicians' response to clinical query generated by the CDI team, building and expanding strategies to decrease queried diagnosis, improving the query response time and other response metrics that contributes to the success of the CDI program.

• * Provide strategies to minimize risk and reduce provider liability, improve quality scores or loss of inpatient revenue.

• * Effectively communicate teaching points for current and future clinical case studies.

• * Reports to the Medical Director of Utilization Management (UM) and Physician Advisory Services (PAS).

• Performs other duties as assigned.