MD Physician Advisor - Utilization Management - FT/Day - Spalding

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Day (United States of America)Job Summary:The Physician Advisor reports to and is accountable to the Vice President Medical Affairs (VPMA) to impact quality, utilization, patient satisfaction and efficiency metrics through Performance Improvement and education initiatives that will enable the facility to achieve its stated goals. Working in collaboration with the VPMA(s) in the WellStar Health System (WHS), the Physician Advisor (PA) will be involved in the following areas: Utilization Management: The Physician Advisor (PA) will conduct clinical review on cases for commercial payers and medicare advantage plans that are referred by Care Coordination/Case Management staff and/or other health care professionals to assess for appropriateness of care; proper level of care in accordance with hospital objectives for assuring quality patient care and effective, efficient utilization of health care services, and to meet regulatory requirements. Working as a peer to physicians and as a consultant to Care Management and administration, the PA intervenes when practice patterns or behaviors or documentation issues create disparity between pathway standards, intensity of service, severity of illness, patient and family rights, teamwork, or other issues regarding the stewardship of resources for individual patients, diagnostic populations, and the organization as a whole. In the area of Readmissions, the Physician Advisor will help to lead the effort to reduce avoidable readmissions. The Physician Advisor will engage with Physicians, Advanced Practice Professionals, nursing and other ancillary personnel as well as administrative leaders as part of his/her role in Performance Improvement, Resource Utilization and ongoing education on imp8ortant trends in healthcare management. Quality Improvement: In addition to the above duties, the PA will work with the VPMA and the Quality Director or Manager at the hospital on quality improvement initiatives to assist the hospital to achieve its annual goals. Core Responsibilities and Essential Functions:The Physician Advisor (PA) will work closely with the Care Coordination/Care Management team to provide timely consultation and clinical expertise to ensure fiscally responsible and efficient utilization of resources. These duties will include but not be limited to areas such as concurrent assessment of the clinical situation, determination of medical necessity and appropriate level of care, real time feedback to physicians and case managers and all necessary follow-up with appropriate and clear communications of next actions to physicians; care coordinators, social workers, nursing staff and other key people involved in caring for individual patients whose cases have been referred for consultation: a) Assist with level of care and length of stay management. This will include assessment of Inpatient vs. Outpatient Obs. Status; Compliance with 2 MN Rule, assistance with throughput initiatives and care transition issues. b) Lead Readmission reduction initiatives at the facility with the Chairperson of the Readmission PIC and in collaboration with the VPMA. c) Assist with denial management process on a concurrent basis if possible. d) Work closely with the Care Coordination Leadership to expedite case management issues and manage work queues. e) Review and make suggestions regarding resource and service management. f) Assist staff with clinical review of patients. g) Review clinical records for appropriate and accurate clinical documentation to ensure that medical necessity and level of care for services will be substantiated. h) Will work with the Clinical Documentation Excellence Specialists (i.e., CDS/CDI) to assist with physician queries for documentation or clinical criterion clarification. i) Will work with Hospital based physician Medical Director(s) to address throughput, Length of Stay, excess days and other issues and barriers related to the continuum of care to improve efficiency. j) May be involved in development and planning of care for specialized patient populations or those requiring Complex Disease & Care management. k) Plan and develop any programs necessary to help facilitate the management of patient populations through the continuum of care. l) Determine if professionally recognized standards of quality care are met by working with the Quality Department and available resources with appropriate referral to the Peer Review process if necessary. m) Assist in review of any reports from regulatory agencies, i.e., RAC audits, QIO reports, etc. to help determine trends, develop replies to inquiries and action plans for improvement. n) As part of his/her duties, the Physician Advisor will participate in a limited on-call schedule with other colleagues as determined by the team. The expectation is that the PA will be available by phone and electronically to conduct phone consultation and chart review to assist the Care Coordination teams on site for all of the WellStar facilities. 2. Supports planned, sequenced ongoing education about payer and utilization matters, best clinical practice data and research, health care trends, collaborative initiatives and skills, post-acute continuum capabilities, changes in Hospital policies and operations, and other salient subjects to physicians (on staff and private practice), physician assistants and nurse practitioners, Medical students and others. a) Functions as a consultant to the Care Management Department to ensure adequate structure within the Hospital to allow efficient and effective delivery of service. b) Responds in a timely manner to requests to intervene with payers, denials and appeals processes, observation level of care, decisions regarding admission and the transition of patients through levels of care, end-of-life dilemmas, issuance of HINNS or other termination of benefits notification, and other situations as requested or as discovered. c) Serves as an expert resource to physicians and Hospital administration regarding immediate or planned decisions when quality, ethical, regulatory, and/or financial risks may be incurred. d) Leads or co-leads Hospital-wide Complex Care Rounds on a regularly-scheduled (ideally weekly) basis. e) Brings matters of potential or actual problems in physician practices to the attention of the VPMA. f) As requested, serves as an expert clinical resource on development and utilization of established clinical guidelines, order sets, pathways, and other structured care methodologies. g) Uses a panel of physician experts in areas outside own expertise to bring specialty knowledge to bear on complex clinical resource situations, including but not limited to, Infectious Disease, Psychiatry, Radiology, etc. Proactively integrates principles of continuous quality improvement to raise the standard of physician practice and ultimately the practice of the Hospital. h) Assists the VPMA and Director of Care Coordination to facilitate the activities of the Utilization Review Committee and coordinates its activities with other key Performance Improvement committees. i) Participates in the identification of opportunities for the organization to increase market share, flow and capacity, diseases management support of populations, and obtaining grants. j) Performs such other matters as may be reasonably requested by the VPMA from time to time. k) Works with the Quality and Patient Safety Department to assist with attainment of the hospital goals. 3. Meets with VPMA on a regular basis and as often as necessary to review cases; revise objective and subjective targets in cost, quality, and patient satisfaction. Physician Advisor may assist with customer service complaints as needed and at the discretion of the VPMA. Have working knowledge and understanding of Care Management Dashboard and physician profiles. Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct. Required Minimum Education:

• Doctorate Medicine or Doctorate Osteopathic Medicine
• Masters Business Administration/Management-Preferred or Masters Health Administration-Preferred

Required Minimum License(s) and Certification(s):All certifications are required upon hire unless otherwise stated.

• DO - Doctor of Osteopathic Medicine or MD - Medical Doctor

Additional License(s) and Certification(s):board certified in specialty of practice. Preferred Health Care Quality & Management Certification, (i.e. ABQAURP or equivalent) Preferred Required Minimum Experience:Minimum 8 years 8-10 years clinical expereince Required Minimum 1 year One (1) to three (3) years of experience post residency in Utilization Management experience with focus on clinical documentation, medical necessity assessment, billing and coding acumen, business, strategic planning, financial planning and development. Required Required Minimum Skills:communicate and understand verbal and written English language display a positive attitude (see WellStars Credo) Organizational skills that enable the individual to react and perform under stress and emergency situations manage two to three activities at one time on an ongoing basis. Management skills to effectively lead physicians. Must display the character and disposition to foster physician engagement. Time management skills to meet scheduled and non-scheduled operational deadlines analytical skills to prepare and manage budget.

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