Cook County Health
PHYSICIAN ADVISOR- UTILIZATION MANAGEMENT & PHYSICIAN ADVISORY SERVICES
Cook County Health, Chicago, Illinois, United States
PHYSICIAN ADVISOR- UTILIZATION MANAGEMENT & PHYSICIAN ADVISORY SERVICES
LOCATION:
JOHN H. STROGER HOSPITAL UTILIZATION MANAGEMENT & PHYSICIAN ADVISORY SERVICES Applicants may apply for this position online or submit a resume/CV to the following email address: MDRecruit@cookcountyhhs.org. When submitting a resume/CV by email, you must include the job title and posting number in the subject line of your email. An application or resume/CV must be filed for each position which interests you. To receive Veteran Preference, appropriate discharge papers must be attached to the online application or must be included with your emailed resume/CV. Please refer to Veteran Preference document requirements listed on the bottom of this posting.
Job Summary
The Physician Advisor works closely with the medical staff leadership, the entire medical staff, including resident physician house staff, all areas of resource management, case management, 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. This includes working with hospital leadership in developing care management 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.
Typical Duties General functions
Provides one-on-one provider education, when necessary, on a wide array of topics including quality, utilization review, and documentation improvement.
Works closely with the Director of Inpatient Utilization and Case Management to provide oversight to utilization management professional and support staff to appropriateness of patient specific plans, improve denial rates, avoidable days and inefficient use of resources.
Works closely with the Director of Inpatient Care Coordination and care coordination leadership and oversight to improve discharge planning, throughput, length of stay, readmission rates and care transitions.
Works closely with the Clinical Documentation Improvement Manager to improve clinical documentation to reflect quality of care given and improve reimbursement.
Participates as a team member on other committees or subcommittees at the discretion and/or absence of the Medical Director of Utilization Management and Physician Advisory Services (Medical Director).
Facilitates strong working relationship between providers, nursing, clinical documentation specialists, case managers, utilization review staff, coding, and the management team.
Collaborates with IT Department with order set development, review, and implementation to coordinate quality, efficiency, and utilization of order sets.
Collaborates with the Health Information Management, Revenue Cycle team and clinical leaders to develop to optimize documentation quality and reimbursement.
Reviews the utilization of resources and objectively measure the outcomes for inpatient and observation stays and making recommendations.
Reviews cases referred by the denials team and cases under dispute with third party payers and presents the hospital’s case to third party payer Medical Director or Peer Review Board, to overturn denials and receive payment.
Maintains an active clinical workload of at least 50%.
UM & Care Coordination Functions
Reviews medical records of patients identified by Clinical Case Managers or as requested by the healthcare team and making recommendations.
Understands and use of decision support tools such as MCG/InterQual and other appropriate criteria. Documents response to case management referrals and support Case Management in a data-driven approach.
Participates in Daily Interdisciplinary Rounds (IDR) with the Healthcare Team, structured Post IDR meeting and Long Stay meeting with Care Coordination leadership.
Performs medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews making suggestions on resources use and service management.
Identifies barriers to timely discharge and assists with developing solutions to remove those barriers in collaboration with care coordination team and health care team.
Provides regular feedback to physicians regarding level of care, length of stay, and potential quality issues, including request of additional and complete medical record to support placement status or medical necessity.
Provides guidance to ED physicians and ED Case Management regarding status issues and alternatives to acute care when acute care is not warranted.
Reviews cases recommended for issuance of a hospital notice of noncoverage or Important Message from Medicare (HINN) and coordinate the process with the Case Manager for issuance of HINNs.
Assists in clinical reviews related to billing; including initial billings, follow-up reports, and appeals in cases of retrospective denials and recovery audit contractor reviews.
Participates in regulatory audits, investigation, survey, or other relevant reviews 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 payor requirements.
Participates in all organizational efforts to reduce inappropriate readmissions.
Clinical Documentation Improvement functions
Provides education to medical staff and house staff on new clinical practice guidelines, protocols, research evidence and regulatory requirements including, but not limited to, ICD, meaningful use, CMS, Joint Commission and compliance.
Educates specific medical staff departments (e.g., Internal Medicine, Surgery, Family Practice, etc.) at departmental meetings about ICD 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.
Evaluates of Clinical Documentation Improvement (CDI) metrics by Physician performance profiling, physician E&M payment and pay for performance, appropriate hospital reimbursement 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.
Develop structure and implement a CDI integrity program, suitable to CCH clinical staff and Coding team.
Participates in screening for medical necessity, ensuring the appropriate level of care and physicians’ appropriate response to clinical queries using the health systems established guidelines.
Monitor physicians’ response to clinical query generated by the CDI team, building and expanding strategies to decrease queried diagnosis, improving the query response time and other response metrics that contributes to the success of the CDI program.
Provide strategies to minimize risk and reduce provider liability, improve quality scores or loss of inpatient revenue.
Effectively communicate teaching points for current and future clinical case studies.
Reports to the Medical Director of Utilization Management (UM) and Physician Advisory Services (PAS).
Performs other duties as assigned.
Minimum Qualifications
Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school
Must be licensed as a physician in the State of Illinois or have the ability to obtain Illinois physician licensure prior to starting employment
Must be cleared for privileges by Medical Staff Services by start of employment
Board Certification in clinical area of expertise
Three (3) years of clinical practice experience in a large health care system or group practice
Two (2) years of experience using an integrated electronic medical record
One (1) year of experience in Utilization Management, i.e. member of a UM committee
Current Health Care Quality and Management Certification (CHCQM) by ABQAURP or the ability to obtain certification within one year of employment
Preferred Qualifications
Three (3) years of experience working in a multispecialty group practice
Two (2) years of experience using a large scale EMR platform (e.g. Cerner, EPIC)
Current Physician Advisor Certification by ABQAURP
Knowledge, Skills, Abilities And Other Characteristics
Knowledge of current health care regulation, accreditation and licensure requirements for physicians and facilities.
Knowledge of Quality Management, Utilization Management, documentation processes and program structure.
Knowledge of utilization, case management, clinical documentation, and quality guidelines.
Knowledge of applicable Federal, State, and local laws and regulations, Corporate Integrity Program, Code of Ethics, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
Excellent interpersonal skills with ability to build collaborative working relationships with medical staff, clinical staff, finance, and compliance.
Excellent written and oral communication skills; ability to write clearly and succinctly in a variety of communication settings and styles.
Ability to demonstrate a comprehensive knowledge of a broad range of medical/surgical diagnoses, treatment modalities, therapeutic services, and intervention techniques.
Ability and willingness to effectively approach physicians on issues related to quality, documentation and utilization as needed.
Ability to make sound decisions based on criteria of Medicare/Medicaid, other payers and/or other utilization/reimbursement agencies regarding medical necessity and the quality, appropriateness, and efficacy of patient care.
Ability to understand the role of emerging technology and its impact on operational effectiveness and organizational change.
Physical and Environmental Demands This position is functioning within a healthcare environment. The incumbent is responsible for adherence to all hospital and department specific safety requirements, including PPE, hand hygiene, and department/policy procedures.
Benefits Package
Medical, Dental, and Vision Coverage
Basic Term Life Insurance
Pension Plan
Deferred Compensation Program
Paid Holidays, Vacation, and Sick Time
Public Service Loan Forgiveness Program (PSLF)
For further information on our benefits package, please visit the Cook County risk website.
EEO Statement
COOK COUNTY HEALTH AND HOSPITAL SYSTEMS IS AN EQUAL OPPORTUNITY EMPLOYER
Veteran Preference
VETERANS MUST PROVIDE ORIGINAL APPLICABLE DISCHARGE PAPERS OR APPLICABLE STATE ID CARD OR DRIVER’S LICENSE AT TIME OF INTERVIEW. Veteran Preference details follow in the posting.
Important Notices
MUST MEET ALL REQUIRED QUALIFICATIONS AT TIME OF APPLICATION FILING. Some items, such as credentialing, licensure, and background checks, may be contingent upon offer of employment.
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LOCATION:
JOHN H. STROGER HOSPITAL UTILIZATION MANAGEMENT & PHYSICIAN ADVISORY SERVICES Applicants may apply for this position online or submit a resume/CV to the following email address: MDRecruit@cookcountyhhs.org. When submitting a resume/CV by email, you must include the job title and posting number in the subject line of your email. An application or resume/CV must be filed for each position which interests you. To receive Veteran Preference, appropriate discharge papers must be attached to the online application or must be included with your emailed resume/CV. Please refer to Veteran Preference document requirements listed on the bottom of this posting.
Job Summary
The Physician Advisor works closely with the medical staff leadership, the entire medical staff, including resident physician house staff, all areas of resource management, case management, 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. This includes working with hospital leadership in developing care management 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.
Typical Duties General functions
Provides one-on-one provider education, when necessary, on a wide array of topics including quality, utilization review, and documentation improvement.
Works closely with the Director of Inpatient Utilization and Case Management to provide oversight to utilization management professional and support staff to appropriateness of patient specific plans, improve denial rates, avoidable days and inefficient use of resources.
Works closely with the Director of Inpatient Care Coordination and care coordination leadership and oversight to improve discharge planning, throughput, length of stay, readmission rates and care transitions.
Works closely with the Clinical Documentation Improvement Manager to improve clinical documentation to reflect quality of care given and improve reimbursement.
Participates as a team member on other committees or subcommittees at the discretion and/or absence of the Medical Director of Utilization Management and Physician Advisory Services (Medical Director).
Facilitates strong working relationship between providers, nursing, clinical documentation specialists, case managers, utilization review staff, coding, and the management team.
Collaborates with IT Department with order set development, review, and implementation to coordinate quality, efficiency, and utilization of order sets.
Collaborates with the Health Information Management, Revenue Cycle team and clinical leaders to develop to optimize documentation quality and reimbursement.
Reviews the utilization of resources and objectively measure the outcomes for inpatient and observation stays and making recommendations.
Reviews cases referred by the denials team and cases under dispute with third party payers and presents the hospital’s case to third party payer Medical Director or Peer Review Board, to overturn denials and receive payment.
Maintains an active clinical workload of at least 50%.
UM & Care Coordination Functions
Reviews medical records of patients identified by Clinical Case Managers or as requested by the healthcare team and making recommendations.
Understands and use of decision support tools such as MCG/InterQual and other appropriate criteria. Documents response to case management referrals and support Case Management in a data-driven approach.
Participates in Daily Interdisciplinary Rounds (IDR) with the Healthcare Team, structured Post IDR meeting and Long Stay meeting with Care Coordination leadership.
Performs medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews making suggestions on resources use and service management.
Identifies barriers to timely discharge and assists with developing solutions to remove those barriers in collaboration with care coordination team and health care team.
Provides regular feedback to physicians regarding level of care, length of stay, and potential quality issues, including request of additional and complete medical record to support placement status or medical necessity.
Provides guidance to ED physicians and ED Case Management regarding status issues and alternatives to acute care when acute care is not warranted.
Reviews cases recommended for issuance of a hospital notice of noncoverage or Important Message from Medicare (HINN) and coordinate the process with the Case Manager for issuance of HINNs.
Assists in clinical reviews related to billing; including initial billings, follow-up reports, and appeals in cases of retrospective denials and recovery audit contractor reviews.
Participates in regulatory audits, investigation, survey, or other relevant reviews 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 payor requirements.
Participates in all organizational efforts to reduce inappropriate readmissions.
Clinical Documentation Improvement functions
Provides education to medical staff and house staff on new clinical practice guidelines, protocols, research evidence and regulatory requirements including, but not limited to, ICD, meaningful use, CMS, Joint Commission and compliance.
Educates specific medical staff departments (e.g., Internal Medicine, Surgery, Family Practice, etc.) at departmental meetings about ICD 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.
Evaluates of Clinical Documentation Improvement (CDI) metrics by Physician performance profiling, physician E&M payment and pay for performance, appropriate hospital reimbursement 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.
Develop structure and implement a CDI integrity program, suitable to CCH clinical staff and Coding team.
Participates in screening for medical necessity, ensuring the appropriate level of care and physicians’ appropriate response to clinical queries using the health systems established guidelines.
Monitor physicians’ response to clinical query generated by the CDI team, building and expanding strategies to decrease queried diagnosis, improving the query response time and other response metrics that contributes to the success of the CDI program.
Provide strategies to minimize risk and reduce provider liability, improve quality scores or loss of inpatient revenue.
Effectively communicate teaching points for current and future clinical case studies.
Reports to the Medical Director of Utilization Management (UM) and Physician Advisory Services (PAS).
Performs other duties as assigned.
Minimum Qualifications
Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school
Must be licensed as a physician in the State of Illinois or have the ability to obtain Illinois physician licensure prior to starting employment
Must be cleared for privileges by Medical Staff Services by start of employment
Board Certification in clinical area of expertise
Three (3) years of clinical practice experience in a large health care system or group practice
Two (2) years of experience using an integrated electronic medical record
One (1) year of experience in Utilization Management, i.e. member of a UM committee
Current Health Care Quality and Management Certification (CHCQM) by ABQAURP or the ability to obtain certification within one year of employment
Preferred Qualifications
Three (3) years of experience working in a multispecialty group practice
Two (2) years of experience using a large scale EMR platform (e.g. Cerner, EPIC)
Current Physician Advisor Certification by ABQAURP
Knowledge, Skills, Abilities And Other Characteristics
Knowledge of current health care regulation, accreditation and licensure requirements for physicians and facilities.
Knowledge of Quality Management, Utilization Management, documentation processes and program structure.
Knowledge of utilization, case management, clinical documentation, and quality guidelines.
Knowledge of applicable Federal, State, and local laws and regulations, Corporate Integrity Program, Code of Ethics, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
Excellent interpersonal skills with ability to build collaborative working relationships with medical staff, clinical staff, finance, and compliance.
Excellent written and oral communication skills; ability to write clearly and succinctly in a variety of communication settings and styles.
Ability to demonstrate a comprehensive knowledge of a broad range of medical/surgical diagnoses, treatment modalities, therapeutic services, and intervention techniques.
Ability and willingness to effectively approach physicians on issues related to quality, documentation and utilization as needed.
Ability to make sound decisions based on criteria of Medicare/Medicaid, other payers and/or other utilization/reimbursement agencies regarding medical necessity and the quality, appropriateness, and efficacy of patient care.
Ability to understand the role of emerging technology and its impact on operational effectiveness and organizational change.
Physical and Environmental Demands This position is functioning within a healthcare environment. The incumbent is responsible for adherence to all hospital and department specific safety requirements, including PPE, hand hygiene, and department/policy procedures.
Benefits Package
Medical, Dental, and Vision Coverage
Basic Term Life Insurance
Pension Plan
Deferred Compensation Program
Paid Holidays, Vacation, and Sick Time
Public Service Loan Forgiveness Program (PSLF)
For further information on our benefits package, please visit the Cook County risk website.
EEO Statement
COOK COUNTY HEALTH AND HOSPITAL SYSTEMS IS AN EQUAL OPPORTUNITY EMPLOYER
Veteran Preference
VETERANS MUST PROVIDE ORIGINAL APPLICABLE DISCHARGE PAPERS OR APPLICABLE STATE ID CARD OR DRIVER’S LICENSE AT TIME OF INTERVIEW. Veteran Preference details follow in the posting.
Important Notices
MUST MEET ALL REQUIRED QUALIFICATIONS AT TIME OF APPLICATION FILING. Some items, such as credentialing, licensure, and background checks, may be contingent upon offer of employment.
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