Physician Advisor Lead

Physician Advisor Lead at Nuvance Health summary :

The Physician Advisor Lead provides leadership and expertise in clinical utilization management, documentation, and denial prevention within a healthcare organization. They oversee physician advisors, standardize policies, and collaborate with various departments to ensure appropriate patient care and compliance with regulatory requirements. The role involves clinical review, denial management, peer-to-peer appeals, and educational support for medical staff.

Description

Summary :

Provides physician leadership and expertise related to appropriate utilization / level of care (LOC) and appropriate clinical documentation. Provides oversight for other Physician Advisors for both the centralized denial prevention unit and the local hospitals. Collaborates with appropriate departments, leaders and committees to meet established goals for physician participation and compliance with expectations.

Responsibilities :

• Provides physician leadership for physician advisors and physicians throughout the organization.
• Manages processes, policies, workflows and overall management of the physician advisor role within the organization.
• Works to lead standardization of policy, procedure and approach to physician advisor roles in utilization management, , documentation and denials / downgrades.
• Serves as physician expert and provides support to care team and denial prevention and denial management team members regarding utilization decisions including screening for appropriateness of hospitalization, LOC status, LOS management, continued stay decisions, clinical review of patients, utilization review activities, resource utilization / management, denial management issues, and potentially quality issues.
• Functions as a consultant and resource to other Physician Advisors and primary (attending) physicians.
• ;Assists Denial Prevention and Denial Management teams with complex cases requiring Physician Advisor expertise to support both peer to peers as well as creation and / or review of appeal letters to overturn retrospective denials.
• Supports care team to ensure appropriate patient placement, care / discharge / etc.
• Ensures medical staff have understanding and compliance with applicable areas of expertise.
• Provides instructional input and education to medical staff as appropriate.
• Maintains knowledge of regulatory and accreditation requirements related to utilization review (UR) LOC and clinical documentation.
• Conducts verbal and written Peer to Peer reviews to assist with appeals of denied or downgraded coverage determinations by managed care, commercial payers, and recovery audit contractors.
• Maintain and Model the organization's values
• Demonstrates regular, reliable and predictable attendance
• Performs other duties as required

Other Information :

Education Skills Experience

Working Conditions :

Manual : Some manual skills / motor coord & finger dexterity

Occupational : Little or no potential for occupational risk

Physical Effort : Sedentary / light effort. May exert up to 10 lbs. force

Physical Environment : Generally pleasant working conditions

Company : Nuvance Health

Org Unit : 1768

Department : Denial Mgmt

Exempt : Yes

Salary Range : $0.00 - $1000.00 Hourly

Keywords :

Physician Advisor, Utilization Management, Clinical Documentation, Denial Management, Level of Care, Peer-to-Peer Review, Healthcare Compliance, Medical Staff Education, Hospital Administration, Utilization Review