Presbyterian Healthcare Services
MD-Physician Advisor-CDS-PRN
Presbyterian Healthcare Services, Albuquerque, New Mexico, United States, 87101
MD-Physician Advisor-CDS-PRN page is loaded## MD-Physician Advisor-CDS-PRNremote type:
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Presbyterian Hospitaltime type:
PRNposted on:
Posted 3 Days Agojob requisition id:
R-369**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 CommissionClinical 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 careESSENTIAL 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 informalAcute 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 requirementsPHYSICIAN 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 issuesCLINICAL 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 payersADDITIONAL 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:**Minimum Job Specifications:\*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 #J-18808-Ljbffr
Virtuallocations:
Presbyterian Hospitaltime type:
PRNposted on:
Posted 3 Days Agojob requisition id:
R-369**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 CommissionClinical 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 careESSENTIAL 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 informalAcute 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 requirementsPHYSICIAN 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 issuesCLINICAL 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 payersADDITIONAL 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:**Minimum Job Specifications:\*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 #J-18808-Ljbffr