Description
This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at Ochsner's discretion.
Training, Certification and Skills
Member of (1) American College of Physician Advisors (ACPA) or (2) Board Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or (3) Physician Advisor Sub-Specialty Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or (4) commitment to apply for such certifications
Demonstrated ability to build rapport with medical staff and hospital leadership.
Comfortable having challenging conversations
Strong computer skills and working knowledge of EMRs
Demonstrated ability to deliver high quality, cost-effective, efficient patient care services
Utilization Management experience (preferred)
Familiarity with: Current medical literature, Healthcare reimbursement issues (e.g., medical necessity, levels of care, coding), MCG / InterQual screening criteria, Medicare / Medicaid compliance, medical staff structure, policies and procedures
Physician Advisors will have access to the required reports and data to make decisions, and to all pertinent federal, state regulations, laws, and policies and facilitate dissemination of relevant information to hospital clinical staff as appropriate.
Essential Position Duties
Create and Sustain Partnerships
Partner and collaborate with stakeholders in the support of appropriate management of patient care activities; Intercede on issues as needed to gain appropriate resolution (especially via direct with Provider communication; includes Case Managers, Coding, Revenue Cycle, Insurance Companies)
Respond to requests for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management department in a timely fashion.
Work with physicians on concurrent appeals (peer to peers)-discussions, appeals and denials
Serve as an education resource to clinical and non-clinical personnel regarding medical necessity and regulations. (to include administration, providers, and operations teams)
Work side by side with case managers, giving direction and education on patient process flow and provide support to foster trust within medical staff
Manage Patient Flow
Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews
Assist with length of stay management and utilization of resources
Assist with the denial management process
Review medical records of patients identified by case managers or as requested by stakeholders to perform quality and utilization oversight
Provide regular feedback to physicians and all other stake holders regarding level of care, length of stay, and potential quality issues
Recommend and request additional complete medical record documentation to support placement status or medical necessity
Provide direction and support for issuance of a hospital notice of non-coverage/Important Message from Medicare (HINN).
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 participating in recovery audit contractor reviews
Assist Hospital Administration in appeals process for retrospective denials
Assist Hospital Administration and the Medical Staff in connection with any regulatory audits, investigation, survey, or other review of the Departments
Ensure consistency of utilization review services, quality control, and patient safety
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
Participate in review of long stay patients, in conjunction with the Care Management Leadership, Care Management team, and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care
Participate in Interdisciplinary Rounds (IDT) with the Healthcare Team as requested
Provide guidance to ED physicians and ED Case Management regarding status issues and alternatives to acute care when acute care is not warranted
Participate in all organizational efforts to improve quality performance metrics including but not limited to inappropriate readmissions, length of stay and observation initiatives
Provide recommendations on inpatient admissions, outpatient and observation services, or case not appropriate for hospital level services
Review and / or sign condition code 44 cases
Identify and assist in removing barriers to discharge
Provide written summary of activities including, but not limited to: recommendations for patient status, evidenced based support for decision-making, overview of discussions with physicians, plan of care for patient, next steps for interdisciplinary team (if appropriate), and appeal letter.
Serve as Improvement Champion
Participate in and recommend Quality Improvement Initiatives relating to documentation improvement and patient placement
Lead coaching of physicians and new residents on information related to, but not limited to:
Documentation quality and standards
Level of care status
Utilization standards
Participate/Co-Lead UM Committee effort at the hospital level
Education
Participate in ongoing training and education related to the Physician Advisor role and responsibilities including topics related to Utilization Management, Care Management and other related areas as requested
Identify & support education needs of the medical staff with regard to documentation, placement and utilization of resources
Other duties as assigned
Occasionally, other duties may be assigned that relate to the PA's competencies
Performance and Reporting
The physician advisor will report to the Vice President of Medical Affairs. Performance of the physician advisor will be evaluated on metrics relating to
Volume of work activity (esp: physician to physician interactions)
Quality of interaction (e.g.: how it is perceived by the medical staff, other team members)
Utilization process metrics (e.g.: avoidable days, conversions)
Hospital throughput metrics
Appropriate compensating metrics (e.g.: early readmissions)
The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time.
Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.
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