Job DescriptionThe Physician Advisor plays a critical role in optimizing healthcare delivery by providing guidance on medical necessity, utilization management, and quality improvement initiatives. They collaborate with healthcare teams to ensure compliance with regulatory standards and promote cost-effective care delivery. This is a full-time position reports to the Chief Medical Officer. Candidates can inquire about part-time availability.
Key Functional Duties: - Utilization Review: Review medical records and documentation to assess the appropriateness of services rendered and ensure compliance with regulatory guidelines.
- Medical Necessity Determination: Evaluate the medical necessity of procedures, treatments, and hospital admissions/level of care (Inpatient vs. observation) based on established criteria and guidelines.
- Optimizing Discharge Planning: Collaborate with case managers, Social works, and healthcare providers to develop care plans that meet patients' clinical needs while optimizing resource utilization to improve Length of Stay. Work with the other stakeholders to optimize IDR
- Denial Management: Lead the denial appeal process to optimize the resolution of insurance denials by providing clinical expertise and supporting appeals processes. The Physician advisor will identify trends in denial cases, perform root cause analysis, and develop actionable plans to prevent future denials. This includes providing targeted physician education on documentation best practices and ensuring alignment with appropriate ICD-10 coding and medical necessity criteria
- Education and Training: Provide education and training to healthcare professionals on utilization management principles, documentation requirements, and regulatory compliance.
- CDI: Collaborate with CDI to ensure appropriate physician documentation with a goal to improve utilization, CMI, and risk adjusted quality measures
- Intradisciplinary Collaboration: Work closely with physicians, nurses, administrators, and other stakeholders to promote effective communication and coordination of care.
- Policy Development: Contribute to the development and revision of utilization management policies, protocols, and procedures.
- Leading the Utilization Management Committee
- Performance Monitoring: Monitor and evaluate key performance indicators related to utilization management, quality of care, and financial outcomes.
- Clinical duties: up to 25% of the position
- Perform other duties as assigned by the CMO
QualificationsRequired Qualifications- Medical degree (MD or DO)
- Medical license
- Knowledge of utilization management principles, regulatory requirements, and healthcare economics.
- Strong analytical skills and attention to detail.
- Excellent communication and interpersonal skills.
- Ability to work independently and collaboratively in a fast-paced environment.
Preferred Qualifications- Experience with electronic health records (EHR) and healthcare information systems.
- Clinical experience in a hospital or healthcare setting.
Total compensation of $275,000 - $325,000.
About the TeamExecutive Order Pursuant to Executive Order 161, no State entity, as defined by the Executive Order, is permitted to ask, or mandate, in any form, that an applicant for employment provide his or her current compensation, or any prior compensation history, until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time, please contact the Governor's Office of Employee Relations at [redacted] or via email at [redacted].
