The Physician Advisor (PA) conducts clinical case reviews referred by case management staff, other healthcare professionals or health plans to meet regulatory requirements and in accordance with the hospital’s objectives for assuring quality patient care and effective and efficient utilization of health care services.
The PA is a physician serving the hospital through teaching, consulting, and advising physicians and the Case Management department on matters regarding physician practice patterns, documentation, over-and-under utilization of resources, medical necessity, compliance rules and regulations, collaboration and relationship with payors, and the community.
The PA also facilitates physician support and execution for Case Management department initiatives by promoting effective and efficient physician documentation to support the patient’s level of care, billing status, and appropriateness of Medicare Severity-Diagnosis Related Group assignment.
● Conducts medical record review in appropriate cases for medical necessity of admission, need for continue hospital stay, adequacy of discharge planning and quality case management.
● Understands the intricacies of ICD-10-CM/PCS, MS-DRG, APR-DRG, Milliman & Roberston, and the Medicare Inpatient Prospective Payment System (IPPS) to make medical determinations on severity of illness, acuity, risk of mortality, and communicate with attending physicians in cooperation with the utilization team.
● Advise, assist and educate attending physicians, case managers, senior medical management administration and all others involved in the delivery of timely, appropriate and cost effective care.
● Conducts verbal and written review and appeal of denied or downgraded coverage determinations.
● Promote hospital adherence to ensure compliance with CMS policy regarding inpatient admissions and observation level of care, as well as the appropriateness of continued hospital stay.
● Daily concurrent chart review on an as needed basis by the case managers to review current treatment plans, identify unnecessary delays in care, and assist the case managers in facilitating care within the health system and functioning as a liaison to the attending physicians in order to provide the highest quality of care in the most efficient manner possible.
● Discuss and educate attending physicians regarding alternative courses of action or modification to the treatment plan, including but not limited to, appropriate documentation of the plan of care, to resolve utilization issues.
● Conducts Peer to Peer discussions with payers as needed. Acts as a liaison and coordinator with Administration for physicians.
● Attends applicable committee meetings, including Chair of Utilization Review Committee.
Sedentary work - Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time.
MedicalDegree(M.D. or D.O.), Medical License (M.D. or D.O.) - South Dakota Board of Medical and Osteopathic Examiners - South Dakota Board of Medical and Osteopathic Examiners