The Physician Advisor works closely with the medical staff leadership, medical staff, including resident physician house staff, all areas of resource management, case management, social services, 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. Supports the Revenue (Rev) Cycle, serving as a liaison between Rev Cycle and the medical staff members across the system, communicating with physicians and other health professionals This includes working with hospitals for efficient management of resources, insuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities.

The Physician Advisor reports directly to the: Medical Director if the Internal Physician Advisor Service (IPAS).

PRINCIPLE DUTIES AND RESPONSIBILITIES:

ACUTE INPATIENT/CASE MANAGEMENT FUNCTIONS:

1. Review medical records of patients identified by UM or as requested by the healthcare team to perform quality and utilization oversight
2. Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews
3. Perform Peer-to-Peer calls for inpatient and post-acute care denials
4. Assist with length of stay management and utilization of resources
5. Review and make suggestions related to resource and service management
6. Provide regular feedback to physicians and all other stake holders regarding level of care, length of stay, and potential quality issues
7. Recommend and request additional and more complete medical record documentation to support placement status or medical necessity
8. Understand and use MCG/InterQual and other appropriate criteria. Document response to UM referrals. Support case management and physicians in the post-acute care process
9. Assist Hospital Administration and the Medical Staff in connection with any regulatory audits, investigation, survey, or other review of the Departments
10. Ensure consistency of utilization review services, quality control, and patient safety
11. Act 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
12. Facilitate, mentor, and educate other physicians regarding payer requirements
13. Provide guidance to ED physicians and Access Care regarding status issues and alternatives to acute care when acute care is not warranted
14. Participate in all organizational efforts to reduce inappropriate readmissions

PHYSICIAN SUPPORT, EDUCATION, AND COLLABORATION:

1. Provide education to physicians and other clinicians related to regulatory requirements, appropriate utilization of hospital services, community resources, and alternative levels of care.
2. Provide education to physicians and other clinicians regarding inappropriate admissions and create action plans to address this issue.
3. Provide physician coaching and on-going education on appropriate clinical documentation improvement and care standards as may be appropriate.

PHYSICIAN LIAISON:

1. Conducts physician education sessions to share data, trends, practice patterns, and other relevant information as requested.
2. Works with hospital UM Medical Directors to:
   • Ensures physician accountability for efficient patient care management.
   • Investigates avoidable delay concerns referred by case management staff that affect patients' outcomes during their hospital stay.
   • Contacts physicians in a timely manner to resolve delays and achieve positive outcomes.
   • Demonstrates positive outcomes through interventions with attending or consulting physicians that delay care and affect the length of stay or avoidable delays, etc.
   • Identifies denial trends and works with the medical staff and hospital administration to resolve the issue.
3. Reports practice pattern trends and opportunities to service line or department specific meetings at the request of hospital leadership.

ORGANIZATIONAL PROCESS IMPROVEMENT:

1. Promote and educate healthcare teams on a team approach to patient care. Promotes coordination, communication, and collaboration among all team members.
2. Support the organization in quality improvement efforts requiring physician input and/or involvement.

MEDICAL INFORMATICS SUPPORT:

1. Works with the IT Leadership team to ensure the system appropriately supports the physician's ability to provide best practice medicine by creating logical processes and providing the necessary order sets and practice guidelines.
2. Participates in physician education and outreach efforts.
3. Works in collaboration with the IT team to be sure all necessary physicians are trained, and training is appropriate for the physicians.
4. Assists with order set development, review, and implementation to coordinate quality, efficiency, and utilization of the order sets, as requested.
5. Attend all meetings as requested by Revenue Cycle and hospital administrations and include Participation in assigned Hospital committees, meetings, and other activities, such as hospital quality and performance committees, medical audit and utilization review committees, and Hospital quality assurance committees.
6. Upon request, actively participate in Hospital committees to develop protocols related to evidence-based medicine and support optimal standards of care.
7. Participate in the educational programs conducted by the Hospital to the extent necessary to ensure the Hospital’s overall compliance with accrediting and regulatory requirements.
8. Ensure the timely, accurate, and adequate completion of all medical records, including sufficient documentation of medical necessity and correct coding for the services rendered, in compliance with the Medical Staff Bylaws.
9. Participate in risk management and quality assessment and improvement activities.
10. Attend (Hospital) sponsored education programs designed to promote adherence to laws, regulations, policies, and procedures relevant to Physician Advisor.
11. Conduct presentations to Medical Staff, Hospital Board/Administration as warranted as may be related to Physician Advisor areas of expertise or knowledge.
12. Assist with the evaluation of the hospital utilization management program, including adherence to the required CMS Conditions of Pa…