Under the co-direction of the Executive Director of Reimbursement, Chief Medical Information Officer, and Associate Chief Medical Officer, the Physician Advisor Director provides leadership to a team of associate Physician Advisors that supports case management, social work, coding team, utilization review, population health, and other clinical members to provide cost efficient, high quality inpatient and observation care at GBMC Hospital. This management includes level of care reviews, all denial reviews and appeals management for all hospital patients. The Physician Advisor Director is responsible for clinical direction of these services and shall be responsible for the development, implementation and oversight of policies and procedures as they apply to the provision of assigned services.
The Physician Advisor Director is a 0.75 to 1.0 FTE and will report directly to the Associate Chief Medical Officer.
Education:
- Graduate of an accredited medical program. Additional education in utilization and quality management through continuing medical education program and self-study
Licensures/Certifications:
- Licensed as a physician in the State of Maryland
- Board Certified by the American Board of Internal Medicine, or other certifying Board as deemed appropriate by Chief Executive Officer.
Experience:
- 2-4 years of recent experience and expertise in Utilization Management and Clinical Quality Management and 5 years of direct clinical experience.
- Has knowledge of Pay for Performance/VBP initiatives and incentives.
Skills:
- A high level of interpersonal skills to allow effective communications and interaction with a wide variety of hospital personnel, physicians, and the general public
- Documented interest and experience in the education and quality improvement needs for the various service lines under his/her responsibility
- Familiarity with Clinical Documentation requirements and working knowledge of Centers for Medicare and Medicaid services, rules and regulations.
Principal Duties and Responsibilities:
- Serves as physician expert and provides support to care team and Case Management, UR and Social Work staff regarding utilization decisions including screening for appropriateness of hospitalization, Level of Care (LOC), patient billing status management, Length of Stay LOS) management, continued stay decisions, clinical review of patients, utilization review activities, resource utilization/management, denial management issues, transitions of care/discharge planning (TOC/DP) advice, and quality of care issues
- Works productively with all department leaders to ensure that clinical care is consistent with current scientific advances and best evidence existing in published clinical literature or as established by recognized professional associations.
- Provides input at least annually for strategic and operational planning purposes and an assessment of Case Management, UR and DC/TOC efficiency and effectiveness.
- Makes recommendations to the Hospital’s administration regarding the use of hospital personnel, any necessary equipment, and general quality standards of patient care.
- Provides leadership and support to develop and maintain effective UM coverage at all points of entry to the Hospital (POE’s). POE process should be inclusive of UR appropriateness, admission avoidance, discharge planning and internal/external resource utilization.
- Supports effort to formalize PA, CM, and Revenue Cycle department operational integration (weekly or bi-weekly) to ensure claims are paid, and that medical necessity issues are addressed concurrently.
- Review denials for patients in the hospital or recently discharged and conduct peer-to-peer consultations with attending physicians as appropriate.
- Review requests for accommodation codes, reviews daily report for status change for Medicare patients and other requests for status and makes recommendations/decisions based on consultations with attending physician.
- Reviews all denials and is responsible for the administration of the appeals process, including completion of appeal letters, and communication & education of medical staff.
- Provide oversight of the development and approval of all operating policies and procedures for Physician Advisor services in conjunction with the responsible Administrator.
- Represents, or appoints designee to represent the hospital’s interests to external organizations concerned with denial management/Medicare or insurance providers.
- Collaborates with PA peers/mentors on an inter-rater reliability (IRR) process to capture standardized policies and procedures that can be used to support overall program strategy and utilization management approach.
- Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, and alternative levels of care
- Educates specific medical staff departments (Hospitalists, Surgery, Residents, etc.) at department meetings regarding correct disease reporting, ICD code assignment, capture of severity and overall hospital reimbursement policies.
- Liaison to Utilization Review, HIM/CDI, EHR and various quality teams throughout the hospital
- Assists in the dissemination of “Best Practice” information.
- Ensures commitment to GBMC service excellence standards and goal of being a best-in-class provider with:
- Maintaining positive attitude and professional appearance
- Respecting others
- Assisting others
- Doing what is right
- Displaying courteous behavior
- Promoting service excellence education and application of principles
- Consistently sharing physician-specific service results
- Ensuring patient satisfaction with physicians and physician extenders which exceeds nation standards
- Chairs the monthly Utilization Management (UM) Medical Staff Committee.
- Moderates and/or resolves conflict among physicians and other health care providers. Provide support for staff in difficult situations.
- Works to ensure initial or continued accreditation through the following: Collaborate with colleagues in quality and other departments to ensure all accrediting body requirements are met.
- Participate in regulatory or accreditation reviews or audits.
- Maintains knowledge of regulatory and accreditation requirements related to utilization review (UR), Discharge Planning, Level of Care, patient billing status management, and clinical documentation.
- Collaborates with hospital and quality department leadership to: a. Ensure medical staff’s understanding and compliance with accreditation and regulatory management activities, b. Identify gaps in physician practice related to standards and regulations, c. Develop action plans to address identified gaps in regulatory requirements, d. Provide education and information to clinical groups regarding changes to practice and/or standards, e. Support quality improvement projects to streamline processes and address gaps, f. Prepare for surveys and participate in surveys, as appropriate.
- Collaborates with CM, Clinical Documentation Integrity (CDI), and Revenue Cycle on strategic initiatives to improve the efficiency of the PA program.
Pay Range
$148,140.24 - $266,652.44
Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.
