Job Description Summary:

As the physician advisor (PA), this role educates, informs, and advises members of the Utilization Management, Health Information Management (HIM), Revenue Cycle, Patient Financial Services, Patient Access, AHS Managed Care departments and applicable medical staff of specific updates, statistical trending and/or changes related to denial prevention measures for our contracted managed care payers.

The PA role is responsible for providing physician review of utilization, claims management, and quality assurance related to inpatient care, outpatient care/observation stays and referral services. This position supports and interfaces with the CMO capacities at all facilities within the Central Florida Division - South Region by ensuring the delivery of high-quality, efficient healthcare services throughout the continuum of care for the membership served by contracted medical group provider networks.

The PA is an important contact for clinicians, external providers, contracted health insurance payers, and regulatory agencies. It also serves as subject matter expert, providing clinical expertise and business direction in support of medical management programs, promoting the delivery of high quality, patient focused and cost-effective medical care. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

Job Description:

• SCOPE OF RESPONSIBILITY: Responsible for reviewing and authorizing inpatient days and the evaluation of inpatient utilization patterns within service areas to identify areas of improvement, developing specific strategies and criteria addressing areas of need. Collaborates with Senior Medical Officers with contracted managed care payers regarding utilization review management activities and maintain a positive and supportive relationship between the inpatient facilities, health plans and physicians (hospitalist groups and primary care providers). Works in close coordination with the processes of the Utilization Review Management staff for continual process improvement and reporting. Reviews and makes recommendations on appealed provider claims. Provides support, shares administrative call, and maintains collaborative relations with the other medical directors. Advise and educate Utilization Management staff regarding clinical issues. Acts as liaison for and with attending physicians to arrive at most appropriate inpatient/outpatient utilization determinations. Assists in other duties related to utilization review and quality improvement of the network as assigned by the Division CFO/Sr VP, Vice President of Revenue Cycle Operations and/or Executive Director Middle Revenue Cycle/Utilization Management. Reviews data and trends to identify opportunities for utilization improvement to positively influence practice patterns. Conducts regular, ongoing meetings with Utilization Management to ensure continuity and efficiency in the inpatient setting. Develops utilization benchmarking for specialty groups within the Orlando market. Manages specialty-specific quality screens and utilization outliers. Acts as a liaison between contracted Managed Care/Commercial payers related to managed care denials, Utilization Management and the Hospital's Medical Staff to facilitate the accurate and complete documentation for coding and abstracting of clinical data, capture of severity, acuity and risk of mortality, in addition to DRG assignment. Establishes and maintains a presence within the Medical Staff structure and active participation on applicable committees (i.e. JOC/Payer, Revenue Cycle, Finance Committee, etc.).

• COMPLIANCE/REGULATORY RESPONSIBILITY: Educates, consults, and advises members of the Medical Staff on regulatory updates and changes related to Care Management and/or Utilization Management. Serves as an active participating member of the Utilization Management (UM) Committee by ensuring committee is actively reviewing and acting upon trends identified through data. Provides trend data of denials to assist in improving payer or care delivery behavior.

• OPERATING & CAPITAL BUDGET/FINANCIAL RESPONSIBILITY: Aid in supporting Length of Stay (LOS) strategies (avoidable days) and quality goals. Reviews concurrent payer denials and intervenes with attending and/or consulting physicians and managed care medical directors, as needed, for reconsideration and denial avoidance.

• STRATEGIC PLANNING RESPONSIBILITY: Provides input on developing plans for physician education to meet identified needs and provides information to members of the Medical Staff and clinical departments on Utilization Management guidelines and protocols.

• Graduate from medical school and residency program
• 5+ Recent clinical practice Required
• 3+ years of Physician Advisor experience
• MD - Physician - State Licensure FL Required
• Board certified and eligible for membership on the hospital medical staff

All the benefits and perks you need for you and your family:

• Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance
• Paid Time Off from Day One
• 403-B Retirement Plan
• 4 Weeks 100% Paid Parental Leave
• Career Development
• Whole Person Well-being Resources
• Mental Health Resources and Support
• Pet Benefits

Schedule:

Full time

Shift:

Day (United States of America)

Address:

601 E ROLLINS ST

City:

ORLANDO

State:

Florida

Postal Code:

32803