Corporate Physician Advisor

Job Description

Community Health Systems is one of the nation's leading healthcare providers. Developing and operating healthcare delivery systems in 44 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 78 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.

Summary:

The Physician Advisor (PA) serves as a clinical resource to markets and facilities by providing identification, facilitation, and resolution of denials. The PA will be responsible for timely completion of assigned peer-to-peers and documentation of the outcomes. The PA will also provide physician and UR team education regarding accurate determination and documentation of the admission status/level of care and presence of complications or comorbidities. This role reports to the Corporate VP of Physician Advisor Program

Essential Duties and Responsibilities

• Conducts peer-to-peers with health plan counterparts for denied inpatient services.

• Acts as a liaison with payers to facilitate approvals and prevent any denials. Facilitates, mentors, and educates other physicians regarding payer requirements

• Performs data analysis related to utilization review (UR) metrics and works with hospital utilization management committees upon request to develop, implement, and monitor action plans related to denial reduction and authorization of level of care.

• Offers input on managed care contracting issues, best demonstrated practices, process improvement and utilization management activities, barriers to achieving goals and objectives of initiatives, and denials prevention initiatives.

• Demonstrates leadership, collaboration, and effective communication skills.

• Participate in the concurrent and retrospective appeal peer-review process. Provides oversight to the l denial strategy within the payer process. Schedules and manages meetings with payer medical directors for collaboration and process improvement. Functions as a core team member of the denial management team. Educates physicians on the topics of coding, documentation and appropriate admission status.

• Provides denials management performance oversight across entire workflow from registration to final payment or appeal outcome

Qualifications

Required Education:

MD or DO Degree

Required Experience:

3 years prior experience working for the Payor, Physician Advisor or in a Leadership role

Minimum of 3-5 years of experience in clinical practice.

Preferred Experience:

• Preferred work experience with the payors or as a physician advisor

• Knowledge of InterQual, Milliman or related evidenced based criteria sets.

• Familiar with DRG vs Per Diem reimbursement models.

• Knowledgeable about third party payer source criteria of medical necessity.

• Organized and able to meet deadlines consistently.

Required License/Registration/Certification:

Licensed (or eligible for licensure) Physician (MD/DO) in a state in the United States.

Preferred License/Registration/Certification:

Board Certification Required (Internal Medicine or Family Medicine preferred)

Computer Skills Required:

Computer experience required with skills including but not limited to Google Suite, Microsoft Windows, spreadsheets, and word processing.

Physical Demands:

In order to successfully perform this job, with or without a reasonable accommodation, the following are outlined below:

• The Employee is required to read, review, prepare and analyze written data and figures, using a PC or similar, and should possess visual acuity.

• The Employee may be required to occasionally climb, push, stand, walk, reach, grasp, kneel, stoop, and/or perform repetitive motions.

• The Employee is not substantially exposed to adverse environmental conditions and; therefore, job functions are typically performed under conditions such as those found within general office or administrative work.

Travel requirements are minimal with occasional travel to key markets in CHS.