MD-Physician Advisor-CDS-PRN

Location Address:

1100 Central Ave SE Albuquerque, NM 87106-4930 Type of Opportunity: PRN FTE: 0.00

Summary:

The Physician Advisor is a key member of the healthcare organizations leadership team and is charged with meeting the organizations goals and objectives for assuring the effective, efficient utilization of health care services. The Physician Advisor is a physician serving the hospital through teaching, consulting and advising the Medical Staff, the Utilization Review team, the Case management team and hospital leadership. The Physician Advisor shall develop expertise on matters regarding physician practice patterns, over and under-utilization of resources, medical necessity, levels of care progression, denial management, compliance with governmental and private payer regulations, appropriate physician coding and documentation requirements.
The Physician Advisor works closely with Medical Staff leadership, the entire medical staff, 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 providers, hospital leadership, case management to optimize length of hospital stay, ensuring efficient management of resources and ensuring patients are in the appropriate level of care. This involves reviewing documentation to support current level of care, monitoring appropriate use of diagnostic and therapeutic modalities and ensuring compliance with government and payer rules for continued hospital care.

Job Description:

Organization Expectations:
*Participates in required orientation and training related to the Physician Advisor role
*Meets production standards within established time requirements. Work product and performance meet quality standards
*Maintains confidentiality of patient care and business matters
*Participates in ongoing training and education related to the Physician Advisor role, Utilization Management, Care Management and other related areas as requested
*Help ensure compliance with regulatory bodies such as CMS and Joint Commission
Clinical Effectiveness:
*Provides consultation to nurses and case management regarding complex clinical issues and advises on justification required for continued stay, medical necessity and utilization management.
*Responds to request for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management or Utilization Review department in a timely fashion.
*Maintains accountability for fulfilling the obligations and responsibilities of the role to support the medical staff in the clinical progression of patient care.
*Works closely with Case Management on complex patient issues/discharge barriers to problem solve and expedite transfer to appropriate level of care
ESSENTIAL JOB DUTIES AND ACCOUNTABILITIES:
Other Skills or Special Abilities:
*Excellent customer service and interpersonal skills
*Strong analytical skills, written and verbal communication skills with all levels of internal and external customers
*Strong organizational skills and ability to set priorities and multi-task, demonstrate flexibility, teamwork and is accustomed to change in the healthcare environment
*Ability to effectively present information, both formal and informal
Acute Inpatient/Case Management Functions:
*Assist with length of stay management and utilization of resources
*Review medical records of patients identified by case managers or social workers or as requested by the health care team in order to perform quality and utilization oversight
*Perform medical necessity reviews including initial level of care, secondary reviews and continued stay reviews and document review determinations and actions
*Assist with denial management process by performing case reviews, performing Peer to Peer reviews and determining if formal appeal warranted
*Perform Government One day stay (Inpatient ) reviews and document determinations
*Provide regular feedback to physicians and all other stakeholders regarding level of care, length of stay and potential quality issues
*Recommend and request additional and more complete medical record documentation to support placement status or medical necessity
*Review cases that indicate a need for a hospital issued notice of non-coverage (HINN). Discuss case with the attending physician and if additional clinical information is not available to support continued hospitalization, coordinate the process with Case Management for issuance of the HINN
*Participate in interdisciplinary rounds with the healthcare team
*Participate in Complex (long length of stay) rounds with Case Management team to facilitate use of the most appropriate level of care setting
*Act as liaison with payers to facilitate approvals and prevent denials by participating in peer to peer discussions and reviews
*Facilitate, mentor and educate physicians regarding payer requirements
PHYSICIAN SUPPORT, EDUCATION AND COLLABORATION:
*Provide education to physicians and other clinicians related to regulatory requirements, appropriate utilization of hospital services, community resources and alternative levels of care
*Provide education to physicians and other clinicians regarding inappropriate admissions and work with Service Line Medical Directors if actions plans needed to address issues
*Provide physician coaching and ongoing education on appropriate clinical documentation improvement and care standards as may be appropriate
*Conduct physician education sessions to share data, trends, practice patterns and other relevant information
*Investigate avoidable delay concerns referred by case management team
*Contact physicians in a timely manner to resolve delays and achieve positive outcomes
*Identify denial trends and work with medical staff, Senior Physician Advisor and hospital administration to resolve any issues
CLINICAL DOCUMENTATION IMPROVEMENT SUPPORT:
*Support CDI team in helping physicians to improve documentation
*Effectively communicate physician teaching points for immediate and future clinical case studies
*Explain the importance of clinical documentation to support level of care and to avoid denials by payers
ADDITIONAL EXPECTATIONS AND RESPONSIBILITIES:
*Attend pertinent meetings as requested by Senior Physician Advisor and Hospital Administration
*Serve on the Utilization Management Committee
*Conduct presentations to Medical Staff, Hospital Board/Administration as warranted as may be related to Physician Advisor areas of expertise or knowledge
*Participate in peer review process as may be necessary or warranted
*Become familiar with the CMS Conditions of Participation related to Utilization Review
*Work with contracting to maintain current knowledge of payer regulatory and contract requirements
*Attend continuing education sessions pertaining to utilization and quality management
*Interacts with Presbyterian Health Plan Leadership to ensure coordinated processes are in place specific to utilization management of PHP members admitted to CDS

Additional Job Description:

*Board Certified Physician
*Hold and maintain unrestricted medical license in NM
*Maintain active membership on Hospital Medical Staff
*Possess or acquire solid foundation, knowledge and experience in the areas of CMS guidelines, utilization management, quality improvement and patient safety
*Possess working knowledge of hospital and case management operations
*Strong computer skills and working knowledge of the EMR
*Familiarity with MCG clinical guidelines preferred
*Membership in the American College of Physician Advisors (ACPA) preferred
*Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes

We offer more than the standard benefits!

Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more! In addition, we offer all employees a robust, day one effective benefits plan consisting of medical, dental, vision and more. Exceptional retirement plans - 403b retirement savings program with both matching programs and employer contributions.

Learn more about our employee benefits

Presbyterian is not just a great place to practice medicine, it's where you'll find a different way to make a difference. Our commitment to safe, high-quality care is at the heart of everything we do. Here's a glimpse of what sets us apart:

• Technology and digital platforms allow our clinicians to focus on meaningful work and reduce friction in your practice.

• Innovative care models improve access and free providers to focus on our patients. Clinicians spend more time connecting patients with affordable, innovative solutions that keep them healthy.

• All employees have a Strongline silent alarm badge to help you be - and feel -- safer at work.

• The RESET program is a multi-day immersive retreat designed for clinicians, fostering personal and professional growth. Through interactive sessions, self-reflection, and peer support, participants gain insights, tools, and practices to enhance well-being, resilience, and intentional living.

About Presbyterian Healthcare Services:

Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with over 14,000 employees - including 1,200 providers and 4,000 nurses.

Our health plan serves more than 600,000 members statewide and offers Medicare Advantage, Medicaid and Commercial health plans.

About Our Regional Delivery System

Presbyterian's Regional Delivery System is a network of six hospitals and medical centers throughout rural New Mexico including locations in Clovis, Espanola, Ruidoso, Santa Fe, Socorro and Tucumcari. Our regional facilities are home to more than 1,600 clinical and non-clinical employees who help make Presbyterian the state's largest private employer with nearly 14,000 statewide employees. With a variety of services ranging from general surgery to pediatrics to heart and cancer care, our regional employees are proud to provide close-to-home care for their communities.

Living and Working in New Mexico

Beyond the professional advantages, living in New Mexico offers a unique blend of culture, outdoor adventures, and a diverse community.

• Cultural richness. Immerse yourself in the cultural richness of New Mexico, from historic adobe structures to vibrant festivals celebrating our diverse heritage.

• Outdoor paradise. With over 300 days of sunshine annually, indulge in outdoor activities ranging from hiking the Sandia Mountains to skiing in nearby Taos.

• Community spirit. Our communities are known for their warmth and hospitality, making your transition seamless and enjoyable.

Learn more about New Mexico

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses