Physician Advisor

Orlando Regional Healthcare   •  

Orlando, FL

Industry: Patient Care

  •  

Not Specified years

Posted 363 days ago

The Physician Advisor (PA) conducts clinical reviews on cases referred by care management staff and/or other health care professionals to meet regulatory requirements and in accordance with the hospitals objectives for assuring quality patient care and effective, efficient utilization of health care services. The PA meets with care management and health care team members to discuss selected cases and make recommendations for care, interacting with medical staff members and medical directors of third party payers to discuss the needs of patients and alternative levels of care. The PA acts as consultant to and resource for providers regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources. The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations.

As the Medical Informatics physician advisor, the PA will act as a liaison between the electronic health record (EHR) implementation team and the medical staff ensuring that the system is optimized for effective physician use. The PA helps facilitate training for the physicians.

Essential Functions

• Acts as second-level reviewer through the review of medical records of patients identified by care managers or as requested by the healthcare team in order to:
• Assist with the patient status determination (level of care) and length of stay management
• Assist with the denial management process
• Review and make suggestions related to resource and service management
• Assist staff with the clinical review of patients
• Determine if professionally recognized standards of quality care are met
• Provides feedback to providers regarding level of care, length of stay, and quality issues. Seeks additional clinical information from the providers. Recommends and requests additional, more complete, medical record documentation. Recommends next steps in coordination of care and evidence-based medicine indicators
• Reviews cases that indicate a need for issuance of a hospital notice of non-coverage/Important Message from Medicare. Discusses the case with the attending physician and if additional clinical information is not available, discusses the process for issuance and appeal to the physician


• Documents in patients EHR care reviews, decisions, and other pertinent information.  Understands and uses InterQual and other appropriate criteria. Documents response to case management referrals. Supports Care Management in a data-driven approach
• Notifies the care manager of any conflict of interest in reviewing a particular patient record. Assists with identifying a physician to review such record
• Acts as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate. Facilitates, mentors, and educates other providers regarding payer requirements
• Participates in review of long stay patients, in conjunction with the Care Management Leadership, Care Management Team and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care. Participates in patient rounds with the Healthcare Team as indicated
• Identifies patients who are appropriate for transfer to lower levels of care such as skilled nursing facilities (SNF), palliative care, long-term care, assisted living, LTACH facilities, and hospice. Works with physicians to facilitate referrals as needed
• Provides guidance to ED physicians and ED Care Management regarding status issues and alternatives to acute care when acute care is not warranted


• Works with Care Management and an interdisciplinary team to ensure appropriate continuity of care and to reduce readmissions
• Provides education to providers related to regulatory requirements, appropriate utilization, alternative levels of care, community resources, and end of life care. Works with physicians to facilitate referrals to the continuum of care
• Assists physicians with end of life care, palliative care and hospice care consultations when appropriate
• Provides education to physicians and other clinicians regarding inappropriate admissions to the ICU and creates action plans to address these patients
• Identifies clinical quality, patient safety, satisfaction, and efficiency issues leading to suboptimal care. Takes appropriate action to resolve
• Promotes and educates healthcare team on a team approach to patient care.  Promotes coordination, communication and collaboration among all team members
• Supports the organization in clinical documentation and quality improvement efforts requiring physician input and/or involvement
• Educates individual hospital staff physicians about ICD coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records
• Works with the EHR team and quality officers and performance improvement to ensure the system appropriately supports the physician’s ability to provide best practice medicine by creating logical processes and providing the necessary order sets and practice guidelines
• Participates in physician and graduate medical education and outreach efforts.
• Works in collaboration with the IT team to be sure all necessary all necessary providers are trained and training is appropriate for the providers  
• Participates as part of the physician advisory council to assist IT with clinical decisions for the EHR
• Assists with order set development, review, and implementation to coordinate quality, efficiency, and utilization of the order sets
• Understands current insurance regulations and quality metrics
• Physician Advisors may not review his/her own patient assignments when serving in their advisory capacity

Other Related Functions

• Actively participates in Hospital committees to develop protocols related to evidence based medicine and supports optimal standards of care
• Presentations to Medical Staff, Board, Administration as warranted
• Chairs or serves on the Utilization Management Committee
• Participates in the peer review process; makes suggestions on ways to improve this process
• Assists with the evaluation of the hospital utilization management program
• Maintains current knowledge of federal, state, and payer regulatory and contract requirements
• Attends continuing education sessions pertaining to utilization and quality management
• Additional functions as deemed appropriate and warranted
• Actively participates in Utilization Review
• Assist in the management of denials and appeals
• Participates in the length of stay reduction initiatives
• Serve as a champion for care management and social work functions, transition of care and multidisciplinary care teams

Education/Training

  • Graduate of an accredited medical school. Must have completed training in an accredited residency. Additional education in quality and utilization management through continuing medical education programs and self-study. Must obtain certification as Physician Advisor through an accredited program.

Licensure/Certification

  • Licensed physician in Florida

Experience

  • Surgeon or Hospitlaist preferred
  • Minimum of three (3) years recent experience in clinical practice.
  • Utilization management experience as a member of the UM oversight committee or past physician advisor experiencepreferred

Job ID 140791