Physician Advisor-Utilization Management

Covenant HealthCare

US:MI:SAGINAW

DAY SHIFT

FULL TIME BENEFITED

Summary:

The Physician Advisor acts as a liaison between the physicians, Utilization Management (UM) and Clinical Documentation Integrity (CDI), revenue cycle and the hospital administration. The Physician Advisor works as part of a team and advises physicians and hospital staff on best practices.

The Physician Advisor is responsible for remaining current regarding payer rules, CMS regulations, and hospital contractual relationships. The Physician Advisor must demonstrate excellent customer service and a positive attitude. The Physician Advisor's actions internally and with external payers must be consistent with the standards contained in the Vision, Mission and Values of Covenant HealthCare.

Responsibilities:

Maintain the denial queues.

Perform peer to peer conversations with Medicare advantage, Medicaid health plans, and commercial payers per regulatory and contractual agreements.

Conduct a primary medical necessity review on cases that are in observation status.

Review Code 44 cases.

Maintain Physician Advisor work queue providing feedback on inpatient and observation cases.

Conduct second level medical necessity reviews for all patient cases that do not meet first level inpatient criteria.

Complete the Medicare work queue by evaluating all short stay Medicare FFS cases for self audit and billing of Part A services.

Follow up on query escalations.

Assist manager with CDI/UM education.

Assist manager with all duties otherwise unspecified.

Engage in a collaborative work environment with department manager.

Provides feedback to attendings and consulting physicians regarding clinical status decisions and documentation.

Communicates with physicians regarding escalated CDI/UM issues.

Communicates with the Chief Medical Officer and the MSQI committee on issues that are not resolved at a Physician Advisor to physician level.

Develops CDI/UM huddle educational content.

Collaborates on CDI denials.

Provide education for physicians and APP's at educational meetings.

Utilizes appropriate criteria to assist nurses with UM case review submission.

Utilizes appropriate language for CDI query formation.

Understands compliant query language.

Assist DMG with medical necessity for Clinical Review Meetings with the payers.

Provide metric and data information to manager and director on performance of CDI/UM.

Design and coordinate with IT and the UM technician reports and research projects for advancement of CDI/UM.

Arrange, coordinate, and facilitate the Utilization Management Committee meeting each quarter including working with the UM technician to maintain binders and minutes.

Review HFAP/ACHC standards and changes.

Provide constructive feedback on queries, reviews, and performance in conjunction with the manager.

Participate in continuing education through Racrelief google groups, covenant consulting initiatives and other PA professional societies.

Remain current on regulatory changes for CMS.

Review and distribute the new Inpatient Only Procedure List.

Review and update the Utilization Management Committee Plan and provide a redline copy to the executive team administrative assistant for approval at committees.

Review and work collaboratively with the Manager on CDI/UM process/policies/improvements.

Establish relationships with lead medical directors.

Provide education to the incoming CMU residents regarding CDI/UM.

Participate in national conferences and societies on UM/CDI.

Other information:

EDUCATION/EXPERIENCE REQUIREMENTS

Graduate of an accredited medical school required.

Current State of Michigan medical license required.

Completion of a specialty residency.

Minimum of 3 years of experience in a hospital-based practice setting.

Board certification preferred.

KNOWLEDGE/SILLS/ABILITIES

Demonstrates the ability to develop relationships.

Demonstrated ability to build rapport with medical staff and hospital leadership.

Ability to task switch and prioritize assignments based on revenue deadlines.

Ability to complete tasks by payer deadlines.

Available to work every other weekend and receive phone calls on emergent issues.

Available to work half of all holidays and receive phone calls on emergent issues.

Strong computer skills including application and use of the internet, EPIC, Excel, Powerpoint and Word.

Demonstrated ability to deliver high quality, cost-effective, efficient patient care services.

Utilization Management experience.

Have familiarity with current medical literature, healthcare reimbursement issues (i.e. medical necessity, levels of care, coding), MCG/Inter Qual screening criteria, Medicare/Medicaid compliance, and medical staff structure, policies and procedures.

WORKING CONDITIONS/PHYSICAL REQUIREMENTS

Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.

Constant sitting, talking, or hearing.

Frequent standing, walking, lifting, carrying, and use of hands to finger, handle and feel.

Frequent lift 0-25 lbs.

Frequent near, far, depth perception, color vision, and field of vision.

Occasional push, pull, balance, climbing, stooping, crawling, kneeling, crouching, taste or smell.

Occasional lift 26-50 lbs.

NOTICE REGARDING LATEX SENSITIVITY IN APPLICANTS FOR EMPLOYMENT.

It has been determined that Covenant HealthCare cannot provide a latex safe or latex free work environment at any of its facilities. Unfortunately, that means that any individual, including an applicant or an employee, is likely to be exposed to latex while on Covenant's premises. Therefore, latex tolerance is considered to be an essential function for any position with Covenant.