Physician Advisor - Utilization Mgmt

Job Summary :

Provides medical leadership for the Department by assisting in the planning, development and implementation of program goals and operations, as outlined in contract. Assures compliance with all JCAHO / DNV and other regulatory agency guidelines. Assist with the strategic plans of the organization for growth and development of the department. Attends at least 75% of quarterly medical staff meetings; attends any meeting as directed by medical director or his / her designee.

Participate in peer-to-peer discussions with managed Medicaid, managed Medicare and commercial insurance medical directors.

Provide subject matter expert guidance regarding utilization management activities that involve admission status, medical necessity, CC44, OC72, the two midnight rule, etc. This guidance will be supported by clinical evidence and will be compliant with applicable governmental rules and regulations.

Work with IT to ensure logical processes, best practices, and compliance with CMS regulations.

Promote professional development of the UM staff with a focus on compliant patient status assignments, consistent use and documentation of primary screening criteria (MCG and Indicia), knowledge of the most recent IPO procedure list, IPPS and OPPS annual changes and how they impact status determination, charges, reimbursement, and interrater reliability of the Physician Advisors.

Work collaboratively with Revenue Integrity to reduce denial and appeal burdens and increase revenue by improving the accuracy of initial patient status determinations.

Interface with Compliance as a subject matter expert for government regulations and annual audits.

Assist with the development and driving of improvement initiatives including providing feedback to medical staff regarding utilization management determinations.

Pursue positions as a member of strategic committees outside the organization that will assist the Authority to be aware of current trends, compliance with regulatory guidance, and influence of state and national policy, including :

ACPA (American College of Physician Advisors)

MCG (Physician Advisors Council)

ABQAURP (American Board of Quality Assurance and Utilization Review Physicians)

Serve as member of the URC (Utilization Review Committee).

Serve as member of the Outlier and Recertification meeting.

Provide secondary level physician reviews and continuing stay reviews.

When available, participate in IDR (interdisciplinary rounds) to advise on the improvement of clinical resource utilization and throughput.

Assist with training of all new UM department hires.

Perform such other duties as reasonably requested by Erlanger or otherwise necessary to properly assist in the operations of assigned areas.

Minimum Requirements :

A minimum of 5 years of clinical practice in field of specialty or previous work as a Physician Advisor.

Education :

M.D. or D.O. degree. Completion of an approved residency and, if applicable, fellowship program.

De-escalation training if applicable.

Licensure :

Licensed to practice in the State of Tennessee.

Certification :

Board Certification in practice specialty.

Willing to obtain CHCQM-Board Certified in Health Care Quality Management

Willing to obtain CHCQM-PHYADV- subspecialty Board Certification as a Physician Advisor in HCQM