Aya Healthcare
Qualifications
Doctorate Degree in Medical Field
(Required) Possess or acquires a solid foundation knowledge and/or experience in the areas of utilization management, quality improvement, clinical documentation improvement, and patient safety (Required) Possess a working knowledge of Phoebe Health System organization & case management operations and administrative standards and policies (Required) Strong computer skills and working knowledge of the EMR (Required) Familiarity with MCG Interqual placement status criteria (Preferred) Member of the American College of Physician Advisors (ACPA) (Preferred) Board Certification by the American Board of Quality Assurance and Utilization Review Physicians Inc. (ABQAURP) (Preferred) Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes (Required) Ability to provide medical guidance and support to the VP of Patient Logistics and Care Coordination as well as the Director(s) of Care Management and Phoebe Care Command in meeting operational goals and strategic imperatives (Required) Licenses and Certifications
Required Certifications/Licensures: Medical Degree (Required) Certified Clinical Documentation Specialist (CCDS) (Preferred) Acute Care Functions
Review medical records of patients identified by case managers or as requested by the healthcare team in order to perform quality and utilization oversight Provide guidance to ED physicians and ED Case Management regarding status issues and alternatives to acute care when acute care is not warranted Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews Recommend and request additional and more complete medical record documentation to support placement status or medical necessity Facilitate, mentor, and educate other physicians regarding payer requirements Provide regular feedback to physicians and all other stakeholders regarding the level of care, length of stay, and utilization of resources Review cases that indicate a need for issuance of a hospital notice of non-coverage (Important Message from Medicare HINN) Discuss the case with the attending physician and, if additional clinical information is not available, coordinate the process with the Care Manager for issuance of HINNs Participate in the review of long-stay patients in conjunction with Care Management Leadership, Care Management team, and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care Act 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, concurrently and retrospectively Assist with the denial management process Participate in all organizational efforts to reduce inappropriate readmissions Understand and use MCG InterQual and other appropriate criteria Document response to case management referrals Support Case Management in a data-driven approach Facilitate pre-payment reviews and/or participate in recovery audit contractor reviews Assist Hospital Administration and the Medical Staff in connection with any regulatory audits, investigations, surveys, or other reviews of the Departments Ensure consistency of utilization review services Work with Care Management and an interdisciplinary team to ensure the appropriate continuity of care Physician Support, Education, and Collaboration
Provide education to physicians and other clinicians related to regulatory requirements and appropriate designation of patient status for hospital services Provide education to physicians and other clinicians regarding inappropriate admissions and create action plans to address this issue Provide physician coaching and ongoing education on appropriate clinical documentation improvement and care standards as may be appropriate Physician Liaison
Conduct physician education sessions on regulations regarding patient status determination Contact physicians in a timely manner to resolve throughput delays Demonstrate positive outcomes through interventions with attending or consulting physicians that delay care and affect the length of stay or avoidable delays Identify denial trends and work with the medical staff and hospital administration to resolve the issue Report practice pattern trends and opportunities to service line or department-specific meetings at the request of the CEO, CMO, Vice President of Patient Logistics and Care Coordination, Director of Care Management, or hospital leadership Clinical Documentation Improvement and Medical Necessity Support
Educate individual hospital staff physicians about coding guidelines (e.g., co-morbid conditions, outpatient observation vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records Educate specific medical staff departments (e.g., Internal Medicine, Surgery, Family Practice, etc.) at departmental meetings on coding and documentation improvement guidelines Explain 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 Describe ways to provide improved health record documentation that captures severity, acuity, and risk of mortality Develop, structure, and implement a clinical documentation improvement and integrity program, taking into account the makeup of your medical staff, medical process environment of the hospital, medical coder competency/skill sets, and overall strategic planning of the organization Build strategies for Medicare Important Message compliance in collaboration with care management Develop the skills for screening for medical necessity, ensuring the appropriate level of care, and properly constructing clinical queries using established guidelines Provide strategies to minimize risk and reduce provider liability or loss of inpatient revenue Build and expand upon strategies that contributed to the development and implementation successes of clinical documentation improvement Effectively communicate physician-teaching points for immediate and future clinical case studies Discuss the basis for discussing succinct points with physicians that stress the application of medical records documentation beyond claims data into administrative data Discuss how to recognize when a clinical query is needed with members of the CDI team Outcomes and Deliverables
Submit monthly record of performance metrics or data as requested to the CMO, CEO, and VP of Patient Logistics and Care Coordination Maintain documentation of the number of interventions and resulting outcomes or decisions and provide data on a monthly basis Document education sessions for medical staff on trends, practice patterns, or relevant information Track and report appeal and denial results where Chief Utilization Officer's intervention was required
Doctorate Degree in Medical Field
(Required) Possess or acquires a solid foundation knowledge and/or experience in the areas of utilization management, quality improvement, clinical documentation improvement, and patient safety (Required) Possess a working knowledge of Phoebe Health System organization & case management operations and administrative standards and policies (Required) Strong computer skills and working knowledge of the EMR (Required) Familiarity with MCG Interqual placement status criteria (Preferred) Member of the American College of Physician Advisors (ACPA) (Preferred) Board Certification by the American Board of Quality Assurance and Utilization Review Physicians Inc. (ABQAURP) (Preferred) Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes (Required) Ability to provide medical guidance and support to the VP of Patient Logistics and Care Coordination as well as the Director(s) of Care Management and Phoebe Care Command in meeting operational goals and strategic imperatives (Required) Licenses and Certifications
Required Certifications/Licensures: Medical Degree (Required) Certified Clinical Documentation Specialist (CCDS) (Preferred) Acute Care Functions
Review medical records of patients identified by case managers or as requested by the healthcare team in order to perform quality and utilization oversight Provide guidance to ED physicians and ED Case Management regarding status issues and alternatives to acute care when acute care is not warranted Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews Recommend and request additional and more complete medical record documentation to support placement status or medical necessity Facilitate, mentor, and educate other physicians regarding payer requirements Provide regular feedback to physicians and all other stakeholders regarding the level of care, length of stay, and utilization of resources Review cases that indicate a need for issuance of a hospital notice of non-coverage (Important Message from Medicare HINN) Discuss the case with the attending physician and, if additional clinical information is not available, coordinate the process with the Care Manager for issuance of HINNs Participate in the review of long-stay patients in conjunction with Care Management Leadership, Care Management team, and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care Act 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, concurrently and retrospectively Assist with the denial management process Participate in all organizational efforts to reduce inappropriate readmissions Understand and use MCG InterQual and other appropriate criteria Document response to case management referrals Support Case Management in a data-driven approach Facilitate pre-payment reviews and/or participate in recovery audit contractor reviews Assist Hospital Administration and the Medical Staff in connection with any regulatory audits, investigations, surveys, or other reviews of the Departments Ensure consistency of utilization review services Work with Care Management and an interdisciplinary team to ensure the appropriate continuity of care Physician Support, Education, and Collaboration
Provide education to physicians and other clinicians related to regulatory requirements and appropriate designation of patient status for hospital services Provide education to physicians and other clinicians regarding inappropriate admissions and create action plans to address this issue Provide physician coaching and ongoing education on appropriate clinical documentation improvement and care standards as may be appropriate Physician Liaison
Conduct physician education sessions on regulations regarding patient status determination Contact physicians in a timely manner to resolve throughput delays Demonstrate positive outcomes through interventions with attending or consulting physicians that delay care and affect the length of stay or avoidable delays Identify denial trends and work with the medical staff and hospital administration to resolve the issue Report practice pattern trends and opportunities to service line or department-specific meetings at the request of the CEO, CMO, Vice President of Patient Logistics and Care Coordination, Director of Care Management, or hospital leadership Clinical Documentation Improvement and Medical Necessity Support
Educate individual hospital staff physicians about coding guidelines (e.g., co-morbid conditions, outpatient observation vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records Educate specific medical staff departments (e.g., Internal Medicine, Surgery, Family Practice, etc.) at departmental meetings on coding and documentation improvement guidelines Explain 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 Describe ways to provide improved health record documentation that captures severity, acuity, and risk of mortality Develop, structure, and implement a clinical documentation improvement and integrity program, taking into account the makeup of your medical staff, medical process environment of the hospital, medical coder competency/skill sets, and overall strategic planning of the organization Build strategies for Medicare Important Message compliance in collaboration with care management Develop the skills for screening for medical necessity, ensuring the appropriate level of care, and properly constructing clinical queries using established guidelines Provide strategies to minimize risk and reduce provider liability or loss of inpatient revenue Build and expand upon strategies that contributed to the development and implementation successes of clinical documentation improvement Effectively communicate physician-teaching points for immediate and future clinical case studies Discuss the basis for discussing succinct points with physicians that stress the application of medical records documentation beyond claims data into administrative data Discuss how to recognize when a clinical query is needed with members of the CDI team Outcomes and Deliverables
Submit monthly record of performance metrics or data as requested to the CMO, CEO, and VP of Patient Logistics and Care Coordination Maintain documentation of the number of interventions and resulting outcomes or decisions and provide data on a monthly basis Document education sessions for medical staff on trends, practice patterns, or relevant information Track and report appeal and denial results where Chief Utilization Officer's intervention was required