Presbyterian Healthcare Services
MD-Physician Advisor-CDS-PRN
Presbyterian Healthcare Services, Albuquerque, New Mexico, United States, 87101
Location Address:
1100 Central Avenue SE, Albuquerque, New Mexico 87106-4930, United States of America
Type of Opportunity: PRN
FTE: 0
Summary: JOB PROFILE FOR PHYSICIAN ADVISOR ROLE AT PHS CDS The Physician Advisor is a key member of the healthcare organizations leadership team and is charged with meeting the organizations 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 Medical Staff, the Utilization Review team, the Case management team and 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 progression, denial management, compliance with governmental and private payer regulations, appropriate physician coding and documentation requirements.
PRIMARY SCOPE OF SERVICE: The Physician Advisor works closely with Medical Staff leadership, the entire medical staff, 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 providers, hospital leadership, case management to optimize length of hospital stay, ensuring efficient management of resources and ensuring patients are in the appropriate level of care. This involves reviewing documentation to support current level of care, monitoring appropriate use of diagnostic and therapeutic modalities and ensuring compliance with government and payer rules for continued hospital care.
Job Description: Organization Expectations:
Participates in required orientation and training related to the Physician Advisor role
Meets production standards within established time requirements. Work product and performance meet quality standards
Maintains confidentiality of patient care and business matters
Participates in ongoing training and education related to the Physician Advisor role, Utilization Management, Care Management and other related areas as requested
Help ensure compliance with regulatory bodies such as CMS and Joint Commission
Clinical Effectiveness:
Provides consultation to nurses and case management regarding complex clinical issues and advises on justification required for continued stay, medical necessity and utilization management.
Responds to request for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management or Utilization Review department in a timely fashion.
Maintains accountability for fulfilling the obligations and responsibilities of the role to support the medical staff in the clinical progression of patient care.
Works closely with Case Management on complex patient issues/discharge barriers to problem solve and expedite transfer to appropriate level of care
ESSENTIAL JOB DUTIES AND ACCOUNTABILITIES: Other Skills or Special Abilities
Excellent customer service and interpersonal skills
Strong analytical skills, written and verbal communication skills with all levels of internal and external customers
Strong organizational skills and ability to set priorities and multi-task, demonstrate flexibility, teamwork and is accustomed to change in the healthcare environment
Ability to effectively present information, both formal and informal
Acute Inpatient/Case Management Functions:
Assist with length of stay management and utilization of resources
Review medical records of patients identified by case managers or social workers or as requested by the health care team in order to perform quality and utilization oversight
Perform medical necessity reviews including initial level of care, secondary reviews and continued stay reviews and document review determinations and actions
Assist with denial management process by performing case reviews, performing Peer to Peer reviews and determining if formal appeal warranted
Perform Government One day stay (Inpatient ) reviews and document determinations
Provide regular feedback to physicians and all other stakeholders regarding level of care, length of stay and potential quality issues
Recommend and request additional and more complete medical record documentation to support placement status or medical necessity
Review cases that indicate a need for a hospital issued notice of non-coverage (HINN). Discuss case with the attending physician and if additional clinical information is not available to support continued hospitalization, coordinate the process with Case Management for issuance of the HINN
Participate in interdisciplinary rounds with the healthcare team
Participate in Complex (long length of stay) rounds with Case Management team to facilitate use of the most appropriate level of care setting
Act as liaison with payers to facilitate approvals and prevent denials by participating in peer to peer discussions and reviews
Facilitate, mentor and educate physicians regarding payer requirements
PHYSICIAN SUPPORT, EDUCATION AND COLLABORATION:
Provide education to physicians and other clinicians related to regulatory requirements, appropriate utilization of hospital services, community resources and alternative levels of care
Provide education to physicians and other clinicians regarding inappropriate admissions and work with Service Line Medical Directors if actions plans needed to address issues
Provide physician coaching and ongoing education on appropriate clinical documentation improvement and care standards as may be appropriate
Conduct physician education sessions to share data, trends, practice patterns and other relevant information
Investigate avoidable delay concerns referred by case management team
Contact physicians in a timely manner to resolve delays and achieve positive outcomes
Identify denial trends and work with medical staff, Senior Physician Advisor and hospital administration to resolve any issues
CLINICAL DOCUMENTATION IMPROVEMENT SUPPORT:
Support CDI team in helping physicians to improve documentation
Effectively communicate physician teaching points for immediate and future clinical case studies
Explain the importance of clinical documentation to support level of care and to avoid denials by payers
ADDITIONAL EXPECTATIONS AND RESPONSIBILITIES:
Attend pertinent meetings as requested by Senior Physician Advisor and Hospital Administration
Serve on the Utilization Management Committee
Conduct presentations to Medical Staff, Hospital Board/Administration as warranted as may be related to Physician Advisor areas of expertise or knowledge
Participate in peer review process as may be necessary or warranted
Become familiar with the CMS Conditions of Participation related to Utilization Review
Work with contracting to maintain current knowledge of payer regulatory and contract requirements
Attend continuing education sessions pertaining to utilization and quality management
Interacts with Presbyterian Health Plan Leadership to ensure coordinated processes are in place specific to utilization management of PHP members admitted to CDS
Additional Job Description:
Board Certified Physician
Hold and maintain unrestricted medical license in NM
Maintain active membership on Hospital Medical Staff
Possess or acquire solid foundation, knowledge and experience in the areas of CMS guidelines, utilization management, quality improvement and patient safety
Possess working knowledge of hospital and case management operations
Strong computer skills and working knowledge of the EMR
Familiarity with MCG clinical guidelines preferred
Membership in the American College of Physician Advisors (ACPA) preferred
Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes
Updated: 4/20/17 We offer more than the standard benefits! Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more! In addition, we offer all employees a robust, day one effective benefits plan consisting of medical, dental, vision and more. Exceptional retirement plans - 403b retirement savings program with both matching programs and employer contributions.
Learn more about our employee benefits
Presbyterian is not just a great place to practice medicine, it's where you'll find a different way to make a difference. Our commitment to safe, high-quality care is at the heart of everything we do. Here's a glimpse of what sets us apart:
Technology and digital platforms allow our clinicians to focus on meaningful work and reduce friction in your practice.
Innovative care models improve access and free providers to focus on our patients. Clinicians spend more time connecting patients with affordable, innovative solutions that keep them healthy.
All employees have a Strongline silent alarm badge to help you be - and feel -- safer at work.
The RESET program is a multi-day immersive retreat designed for clinicians, fostering personal and professional growth. Through interactive sessions, self-reflection, and peer support, participants gain insights, tools, and practices to enhance well-being, resilience, and intentional living.
About Presbyterian Healthcare Services: Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with over 14,000 employees - including 1,200 providers and 4,000 nurses.
Our health plan serves more than 600,000 members statewide and offers Medicare Advantage, Medicaid and Commercial health plans.
About Our Regional Delivery System Presbyterian's Regional Delivery System is a network of six hospitals and medical centers throughout rural New Mexico including locations in Clovis, Espanola, Ruidoso, Santa Fe, Socorro and Tucumcari. Our regional facilities are home to more than 1,600 clinical and non-clinical employees who help make Presbyterian the state's largest private employer with nearly 14,000 statewide employees. With a variety of services ranging from general surgery to pediatrics to heart and cancer care, our regional employees are proud to provide close-to-home care for their communities.
Living and Working in New Mexico Beyond the professional advantages, living in New Mexico offers a unique blend of culture, outdoor adventures, and a diverse community.
Cultural richness. Immerse yourself in the cultural richness of New Mexico, from historic adobe structures to vibrant festivals celebrating our diverse heritage.
Outdoor paradise. With over 300 days of sunshine annually, indulge in outdoor activities ranging from hiking the Sandia Mountains to skiing in nearby Taos.
Community spirit. Our communities are known for their warmth and hospitality, making your transition seamless and enjoyable.
Learn more about New Mexico
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses
#J-18808-Ljbffr
Type of Opportunity: PRN
FTE: 0
Summary: JOB PROFILE FOR PHYSICIAN ADVISOR ROLE AT PHS CDS The Physician Advisor is a key member of the healthcare organizations leadership team and is charged with meeting the organizations 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 Medical Staff, the Utilization Review team, the Case management team and 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 progression, denial management, compliance with governmental and private payer regulations, appropriate physician coding and documentation requirements.
PRIMARY SCOPE OF SERVICE: The Physician Advisor works closely with Medical Staff leadership, the entire medical staff, 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 providers, hospital leadership, case management to optimize length of hospital stay, ensuring efficient management of resources and ensuring patients are in the appropriate level of care. This involves reviewing documentation to support current level of care, monitoring appropriate use of diagnostic and therapeutic modalities and ensuring compliance with government and payer rules for continued hospital care.
Job Description: Organization Expectations:
Participates in required orientation and training related to the Physician Advisor role
Meets production standards within established time requirements. Work product and performance meet quality standards
Maintains confidentiality of patient care and business matters
Participates in ongoing training and education related to the Physician Advisor role, Utilization Management, Care Management and other related areas as requested
Help ensure compliance with regulatory bodies such as CMS and Joint Commission
Clinical Effectiveness:
Provides consultation to nurses and case management regarding complex clinical issues and advises on justification required for continued stay, medical necessity and utilization management.
Responds to request for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management or Utilization Review department in a timely fashion.
Maintains accountability for fulfilling the obligations and responsibilities of the role to support the medical staff in the clinical progression of patient care.
Works closely with Case Management on complex patient issues/discharge barriers to problem solve and expedite transfer to appropriate level of care
ESSENTIAL JOB DUTIES AND ACCOUNTABILITIES: Other Skills or Special Abilities
Excellent customer service and interpersonal skills
Strong analytical skills, written and verbal communication skills with all levels of internal and external customers
Strong organizational skills and ability to set priorities and multi-task, demonstrate flexibility, teamwork and is accustomed to change in the healthcare environment
Ability to effectively present information, both formal and informal
Acute Inpatient/Case Management Functions:
Assist with length of stay management and utilization of resources
Review medical records of patients identified by case managers or social workers or as requested by the health care team in order to perform quality and utilization oversight
Perform medical necessity reviews including initial level of care, secondary reviews and continued stay reviews and document review determinations and actions
Assist with denial management process by performing case reviews, performing Peer to Peer reviews and determining if formal appeal warranted
Perform Government One day stay (Inpatient ) reviews and document determinations
Provide regular feedback to physicians and all other stakeholders regarding level of care, length of stay and potential quality issues
Recommend and request additional and more complete medical record documentation to support placement status or medical necessity
Review cases that indicate a need for a hospital issued notice of non-coverage (HINN). Discuss case with the attending physician and if additional clinical information is not available to support continued hospitalization, coordinate the process with Case Management for issuance of the HINN
Participate in interdisciplinary rounds with the healthcare team
Participate in Complex (long length of stay) rounds with Case Management team to facilitate use of the most appropriate level of care setting
Act as liaison with payers to facilitate approvals and prevent denials by participating in peer to peer discussions and reviews
Facilitate, mentor and educate physicians regarding payer requirements
PHYSICIAN SUPPORT, EDUCATION AND COLLABORATION:
Provide education to physicians and other clinicians related to regulatory requirements, appropriate utilization of hospital services, community resources and alternative levels of care
Provide education to physicians and other clinicians regarding inappropriate admissions and work with Service Line Medical Directors if actions plans needed to address issues
Provide physician coaching and ongoing education on appropriate clinical documentation improvement and care standards as may be appropriate
Conduct physician education sessions to share data, trends, practice patterns and other relevant information
Investigate avoidable delay concerns referred by case management team
Contact physicians in a timely manner to resolve delays and achieve positive outcomes
Identify denial trends and work with medical staff, Senior Physician Advisor and hospital administration to resolve any issues
CLINICAL DOCUMENTATION IMPROVEMENT SUPPORT:
Support CDI team in helping physicians to improve documentation
Effectively communicate physician teaching points for immediate and future clinical case studies
Explain the importance of clinical documentation to support level of care and to avoid denials by payers
ADDITIONAL EXPECTATIONS AND RESPONSIBILITIES:
Attend pertinent meetings as requested by Senior Physician Advisor and Hospital Administration
Serve on the Utilization Management Committee
Conduct presentations to Medical Staff, Hospital Board/Administration as warranted as may be related to Physician Advisor areas of expertise or knowledge
Participate in peer review process as may be necessary or warranted
Become familiar with the CMS Conditions of Participation related to Utilization Review
Work with contracting to maintain current knowledge of payer regulatory and contract requirements
Attend continuing education sessions pertaining to utilization and quality management
Interacts with Presbyterian Health Plan Leadership to ensure coordinated processes are in place specific to utilization management of PHP members admitted to CDS
Additional Job Description:
Board Certified Physician
Hold and maintain unrestricted medical license in NM
Maintain active membership on Hospital Medical Staff
Possess or acquire solid foundation, knowledge and experience in the areas of CMS guidelines, utilization management, quality improvement and patient safety
Possess working knowledge of hospital and case management operations
Strong computer skills and working knowledge of the EMR
Familiarity with MCG clinical guidelines preferred
Membership in the American College of Physician Advisors (ACPA) preferred
Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes
Updated: 4/20/17 We offer more than the standard benefits! Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more! In addition, we offer all employees a robust, day one effective benefits plan consisting of medical, dental, vision and more. Exceptional retirement plans - 403b retirement savings program with both matching programs and employer contributions.
Learn more about our employee benefits
Presbyterian is not just a great place to practice medicine, it's where you'll find a different way to make a difference. Our commitment to safe, high-quality care is at the heart of everything we do. Here's a glimpse of what sets us apart:
Technology and digital platforms allow our clinicians to focus on meaningful work and reduce friction in your practice.
Innovative care models improve access and free providers to focus on our patients. Clinicians spend more time connecting patients with affordable, innovative solutions that keep them healthy.
All employees have a Strongline silent alarm badge to help you be - and feel -- safer at work.
The RESET program is a multi-day immersive retreat designed for clinicians, fostering personal and professional growth. Through interactive sessions, self-reflection, and peer support, participants gain insights, tools, and practices to enhance well-being, resilience, and intentional living.
About Presbyterian Healthcare Services: Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with over 14,000 employees - including 1,200 providers and 4,000 nurses.
Our health plan serves more than 600,000 members statewide and offers Medicare Advantage, Medicaid and Commercial health plans.
About Our Regional Delivery System Presbyterian's Regional Delivery System is a network of six hospitals and medical centers throughout rural New Mexico including locations in Clovis, Espanola, Ruidoso, Santa Fe, Socorro and Tucumcari. Our regional facilities are home to more than 1,600 clinical and non-clinical employees who help make Presbyterian the state's largest private employer with nearly 14,000 statewide employees. With a variety of services ranging from general surgery to pediatrics to heart and cancer care, our regional employees are proud to provide close-to-home care for their communities.
Living and Working in New Mexico Beyond the professional advantages, living in New Mexico offers a unique blend of culture, outdoor adventures, and a diverse community.
Cultural richness. Immerse yourself in the cultural richness of New Mexico, from historic adobe structures to vibrant festivals celebrating our diverse heritage.
Outdoor paradise. With over 300 days of sunshine annually, indulge in outdoor activities ranging from hiking the Sandia Mountains to skiing in nearby Taos.
Community spirit. Our communities are known for their warmth and hospitality, making your transition seamless and enjoyable.
Learn more about New Mexico
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses
#J-18808-Ljbffr