As the physician advisor (PA), this role educates, informs, and advises members of the Utilization Management, Health Information Management (HIM), Revenue Cycle, Patient Financial Services, Patient Access, AHS Managed Care departments and applicable medical staff of specific updates, statistical trending and/or changes related to denial prevention measures for our contracted managed care payers. The PA role is responsible for providing physician review of utilization, claims management, and quality assurance related to inpatient care, outpatient care/observation stays and referral services. This position supports and interfaces with the CMO capacities at all facilities within the Central Florida Division – South Region by ensuring the delivery of high-quality, efficient healthcare services throughout the continuum of care for the membership served by contracted medical group provider networks. The PA is an important contact for clinicians, external providers, contracted health insurance payers, and regulatory agencies. It also serves as subject matter expert, providing clinical expertise and business direction in support of medical management programs, promoting the delivery of high quality, patient focused and cost-effective medical care. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
What you will need:
KNOWLEDGE AND SKILLS REQUIRED:
·Strong ability to build and sustain relationships in the medical community and a corporate environment
· Successful history as a practicing physician
·Strong organization skills with attention to detail
· Excellent analytical and problem-solving skills
· Effective oral and written communication skills, with the ability to articulate complex information in understandable terms to all levels of staff
· Ability to work in a matrix-management environment to achieve organizational goals
·Ability to translate ethical and legal requirements into practical and sustainable policies, balancing the needs of the business and the interest of patients and member physicians alike
· Ability to provide expert medical advice and explain complex medical situations
· Successful history as a practicing physician KNOWLEDGE & SKILLS PREFERRED:
·Health plan experience in operations
·Experience in a physician group model, leadership experience
· Effective computer skills, particularly Microsoft Office Outlook, Word, Excel, PowerPoint
· Graduate from medical school and residency program
· Master’s degree in Business or Healthcare Administration or related degree
· Five or more years recent clinical practice experience
· Understanding of hospital Utilization Management/Medicare Regulations
· Two years or greater experience as a Physician Advisor
· Three years of leadership experience
LICENSURE, CERTIFICATION, OR REGISTRATION REQUIRED:
· Current, valid State of Florida license as a physician
· Board certified and eligible for membership on the hospital medical staff
LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED:
PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:
Demonstrates, through behavior, AdventHealth’s core values of Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork
SCOPE OF RESPONSIBILITY:
·Responsible for reviewing and authorizing inpatient days and the evaluation of inpatient utilization patterns within service areas to identify areas of improvement, developing specific strategies and criteria addressing areas of need.
· Collaborates with Senior Medical Officers with contracted managed care payers regarding utilization review management activities and maintain a positive and supportive relationship between the inpatient facilities, health plans and physicians (hospitalist groups and primary care providers).
· Works in close coordination with the processes of the Utilization Review Management staff for continual process improvement and reporting. Reviews and makes recommendations on appealed provider claims.
· Provides support, shares administrative call, and maintains collaborative relations with the other medical directors.
· Advise and educate Utilization Management staff regarding clinical issues. Acts as liaison for and with attending physicians to arrive at most appropriate inpatient/outpatient utilization determinations. Assists in other duties related to utilization review and quality improvement of the network as assigned by the Division CFO/Sr VP, Vice President of Revenue Cycle Operations and/or Executive Director Middle Revenue Cycle/Utilization Management.
· Reviews data and trends to identify opportunities for utilization improvement to positively influence practice patterns. Conducts regular, ongoing meetings with Utilization Management to ensure continuity and efficiency in the inpatient setting.
· Develops utilization benchmarking for specialty groups within the Orlando market. Manages specialty-specific quality screens and utilization outliers.
· Acts as a liaison between contracted Managed Care/Commercial payers related to managed care denials, Utilization Management and the Hospital’s Medical Staff to facilitate the accurate and complete documentation for coding and abstracting of clinical data, capture of severity, acuity and risk of mortality, in addition to DRG assignment. Establishes and maintains a presence within the Medical Staff structure and active participation on applicable committees (i.e. JOC/Payer, Revenue Cycle, Finance Committee, etc.).
· Educates, consults, and advises members of the Medical Staff on regulatory updates and changes related to Care Management and/or Utilization Management.
· Serves as an active participating member of the Utilization Management (UM) Committee by ensuring committee is actively reviewing and acting upon trends identified through data. Provides trend data of denials to assist in improving payer or care delivery behavior.
OPERATING & CAPITAL BUDGET/FINANCIAL RESPONSIBILITY:
· Aid in supporting Length of Stay (LOS) strategies (avoidable days) and quality goals.
· Reviews concurrent payer denials and intervenes with attending and/or consulting physicians and managed care medical directors, as needed, for reconsideration and denial avoidance.
STRATEGIC PLANNING RESPONSIBILITY:
· Provides input on developing plans for physician education to meet identified needs and provides information to members of the Medical Staff and clinical departments on Utilization Management guidelines and protocols.
PERFORMANCE IMPROVEMENT RESPONSIBILITY:
· Provides teaching and guidance to key associates and physicians regarding the impact of responsible stewardship of resources and attainment of important outcomes for each patient and family.
· Responsible for managing the efficiency of inpatient care delivered in the organization and collaborates with all levels of managed care team, utilization review management, hospital executive team including the Chief Medical Officers, and leadership of medical and nursing staff.
· Serves as a liaison between the AH Managed Care Operations, Care Management, PFS, Revenue Cycle, Utilization Review departments, Medical Staff and the Chief Medical Officers for matters related to physician practice and behaviors as they affect cost, quality, documentation and patient outcomes.
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