Physician Advisor

Job Summary:

The Physician Advisor  conducts clinical case reviews referred by case management staff and/or other health care professionals 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. This individual meets with case management and health care team members to discuss selected cases and make recommendations for care as well as 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 performs denials management and prevention in accordance with the organization’s goals and expectations. This individual reviews cases for clinical validation, performs peer-to-peer discussions and participates in appeal letter writing. The PA acts as a consultant to, and resource for, attending physicians regarding their decisions relative to appropriateness of hospitalization, clinical documentation, continued inpatient stay, and use of healthcare resources. The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations. The PA helps facilitate training for physicians. The PA must demonstrate interpersonal and communication skills and must be clear, concise and consistent in the message to all constituents. Exhibits the F.I.R.S.T. values (Friendliness, Innovation, Respect, Service and Trust).

Essential Functions, Duties And Responsibilities:

Utilization Review Committee

• Concurrent Admission Review Includes, but shall not limited to: 

• Continued Stay Review Includes, but shall not be limited to: 

• Concurrent Admission Denials Includes, but shall not be limited to:

Billed Claim Denials

• Clinical Documentation Advisor includes,,but shall not be limited to: 

• Medical Necessity Education Includes, but shall not be limited to: 

Physician Advisor Education:

WORKING CONDITIONS, HAZARDS AND PHYSICAL EFFORT:

The position is primarily performed in an office environment, with the majority of time spent working at a computer workstation and on the telephone. Work involves extended periods of sitting, typing, and viewing a computer screen. Occasional standing, walking, and reaching may be required. The role requires clear and professional verbal communication over the phone, as well as accurate written documentation.Minimal lifting of office supplies or files (generally less than 20 pounds) may occasionally be required.

Contacts With Others:

Actively participates in daily interdisciplinary collaboration with the case management team, including case managers, social workers, and utilization review staff, to thoroughly review and address care plans, medical necessity, and discharge coordination. In addition, engages in ongoing communication with attending providers to support the delivery of safe, effective, and timely care. Collaborates with third-party payors to complete peer-to-peer responsibilities and ensure appropriate authorization and coverage for services. Works closely with other associates, support personnel, and external partners as needed to promote continuity of care, optimize patient outcomes, and achieve overall success in fulfilling the responsibilities of the role.

Equipment Used/Special Skills Required:

Strong computer skills with working knowledge of EMR, familiarity with MCG criteria. Strong analytical, problem-solving, and decision-making skills

Qualifications

Minimum of 3–5 years of recent direct clinical practice experience.