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Physician Advisor

Physician Advisor

St. Charles Health SystemBend, OR, US
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Physician Advisor

The Physician Advisor is a key member of the healthcare organization's leadership team and is charged with meeting the organization's goals and objectives for assuring the effective, efficient utilization of health care services. The Physician Advisor is a physician serving the hospital through teaching, consulting, and advising the care coordination and utilization review departments and the hospital leadership.

The Physician Advisor shall develop expertise on matters regarding physician practice patterns, over and under-utilization of resources, medical necessity, levels of care, care progression, denial management, compliance with governmental and private payer regulations, and appropriate physician documentation requirements. This position does not directly manage other caregivers.

Essential Functions And Duties :

  • Works closely with the medical staff leadership, the entire medical staff, including resident physician house staff, all areas of resource management, care coordination, social services, discharge planning, and utilization management to develop and implement methods to optimize use of hospital services for all patients while also ensuring the quality of care provided.
  • Works with hospital leadership in developing care coordination protocols with physicians and others to optimize length of hospital stay and efficient management of resources, ensuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities.
  • Maintains confidentiality of patient care and business matters. Adheres to all professional and performance expectations set forth within the medical staff bylaws, rules & regulations and complies with all St. Charles Health System established policies and procedures.
  • Participates in ongoing training and education related to the Physician Advisor role and responsibilities including topics related to utilization management, care coordination, and other related areas as requested.
  • Obtains familiarity and working knowledge of standard published criteria such as MCG / InterQual and applies professional judgment and patient specific variables as may be necessary or justifiable.

Clinical Effectiveness :

  • Maintains accountability for achieving care coordination outcomes and fulfills the obligations and responsibilities of the role to support the medical staff in the clinical progression of patient care.
  • Reviews issues identified by case managers to ensure appropriate follow-up, recommend improvement initiatives as needed, and make referrals to the appropriate department chair, as necessary.
  • Responds to requests for assistance on clinical reviews for medical necessity or any other reason, by any member of the care coordination department in a timely fashion.
  • Provides consultation to nurses and care coordination staff regarding complex clinical issues. Advises on justification required for continued stay, medical necessity and utilization management.

    • Acute Inpatient / Care Coordination Functions :

  • Reviews medical records of patients identified by case managers or as requested by the healthcare team to perform quality and utilization oversight.
  • Performs medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews. Assists with length of stay management and utilization of resources. Reviews and makes suggestions related to resource and service management.
  • Performs reviews for determining professionally recognized standards of quality care and provides regular feedback to physicians and all other stakeholders regarding level of care, length of stay, and potential quality issues.
  • Recommends and requests additional and more complete medical record documentation to support placement status or medical necessity.
  • Reviews cases that indicate a need for issuance of a hospital notice of noncoverage / Important Message from Medicare (HINN). Discusses the case with the attending physician and if additional clinical information is not available, coordinates the process with the utilization management team for issuance of HINNs.
  • Understands and uses MCG / InterQual and other appropriate criteria. Documents response to case management referrals. Supports case management in a data-driven approach.
  • Facilitates pre-payment reviews and / or participates in recovery audit contractor reviews.
  • Assists hospital administration in billing for the technical component of the services rendered by the departments, including initial billings, follow-up reports, and appeals in cases of retrospective denials.
  • Assists hospital administration and the medical staff in connection with any regulatory audits, investigation, survey, or other review of the departments.
  • Acts as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate by participating in peer-to-peer discussions and reviews.
  • Facilitates, mentors, and educates other physicians regarding payer requirements.
  • Regularly participates in Interdisciplinary Rounds (IDT) with the healthcare team onsite as indicated.
  • Provides guidance to ED physicians and ED utilization management regarding status issues and alternatives to acute care when acute care is not warranted.
  • Works with care coordination and an interdisciplinary team to ensure appropriate continuity of care.
  • Participates in all organizational efforts to reduce inappropriate readmissions.

    • Physician Support, Education, And Collaboration :

  • Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization of hospital services, community resources, and alternative level of care.
  • Provides education to physicians and other clinicians regarding inappropriate admissions and creates action plans to address this issue.
  • Provides physician coaching and on-going education on appropriate clinical documentation improvement and care standards as may be appropriate. Demonstrates positive outcomes through interventions with attending or consulting physicians that delay care and affect the length of stay or avoidable delays, etc.

    • Physician Liaison :

  • Conducts physician education sessions to share data, trends, practice patterns, and other relevant information as requested.
  • Ensures physician accountability for efficient patient case management.
  • Investigates avoidable delay concerns referred by case management staff that effect patients' outcomes during their hospital stay.
  • Reports practice pattern trends and opportunities to service line or department specific meetings at the request of the CMO or hospital leadership.

    • Clinical Documentation Improvement Support :

  • Educates individual hospital staff physicians about ICD-9 and ICD-10 and DRG 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.
  • Explains reasons why individual physicians should be concerned about correct disease reporting and the subsequent ICD code capture of severity, acuity, risk of mortality, and DRG assignment, such as : Physician performance profiling, physician E&M payment and pay for performance, appropriate hospital reimbursement and profiling for patient care.
  • Describes ways to provide improved health record documentation that specifically affect ICD code assignment capture of severity, acuity, risk of mortality, and DRG assignment.
  • Builds strategies for Medicare important message compliance in collaboration with care management.
  • Develops the skills for screening for medical necessity, ensuring the appropriate level of care and properly crafting clinical queries using established guidelines. Discusses how to recognize when a clinical query is needed with members of the CDI team.
  • Provides strategies to minimize risk and reduce provider liability or loss of inpatient revenue. Builds and expands upon time-tested proven strategies that contributed to the development and implementation successes of clinical documentation improvement.
  • Effectively communicates physician teaching points for immediate and future clinical case studies.
  • Discusses the basis for discussing succinct points with physicians, upon the opportunity to present teaching points that stress the application of medical records documentation beyond claims data into administrative data.
  • Explains the role of administrative data in today's business of medicine - and the future of medicine.

    • Medical Informatics Support :

  • Works with the IT Leadership team 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.
  • Assists with order set development, review, and implementation to coordinate quality, efficiency, and utilization of the order sets, as requested.

    • Clinical Support :

  • Participates in creating a healing environment that supports all aspects of care and honors the wholeness of each individualpatients and caregivers alike.
  • Maintains a safe environment for caregivers, patients, and guests; conducts all activities with professionalism and confidentiality.
  • Delivers exceptional service and care that is timely, efficient, courteous, and aligned with system values.
  • Educates, counsels, and supports patients and families regarding health conditions, maintenance, and preventive practices.
  • Provides a therapeutic presence through meaningful connectionintroducing oneself and purpose, using the patient's preferred name, listening actively, and engaging with compassion.
  • Complies with all laws, regulations, and policies, and supports our corporate
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