Job Summary:

The Physician Advisor is responsible for developing positive relationships with both employed and affiliated medical staff members in order to fulfill strategic business growth and objectives. This position plays an important role in ensuring physician support and execution of for Utilization Management and Documentation strategies and processes.

 Responsibilities:

• Reviews inpatient cases when clinical determinations cannot be made by initial clinical review. 
• Discusses determinations with requesting physicians or ordering providers when available within the regulatory timeframe of the request. 
• Provides clinical rational for standard and expedited appeals.
• Participate in peer-to-peer review with payors and/or complete appeals as required to overturn denials. 
• Provides assistance to initial clinical reviewers as needed to discuss cases and problems. 
• Participates in daily review of aggregate denials/appeals with the Medical Director, peer, or the Clinical Review Supervisor. 
• Provides continuous education to physicians as needed on payor policies and workflows. 
• Utilizes medical review guidelines and parameters to assure consistency in the review process to reflect appropriate utilization and compliance with various organizations. 
• Documents all communications with provider and records in a timely and accurate manner. ·Functions as a resource for initial clinical reviewers. 
• Serves on UM Committee ·Provides Physician administrative support and leadership to the utilization and resource management areas of Integrated Case Management including mentoring/coaching care coordinators, utilization review staff and social workers.
• Reviews cases for medical necessity 
• Conducts daily multidisciplinary rounds with focus on reducing LOS and readmissions. 
• Collaborates with hospitalists, physicians, and house staff in determining appropriate inpatient versus outpatient/observation status and providing feed-back on documentation improvement. 
• Participants in third-party payor denial, appeal, and peer- to- peer processes using MCG/Interqual criteria/guidelines. 
• Performs other duties as assigned.

Qualifications/Requirements:

Experience: Experience as a CDI champion and/or Case management Physician Advisor or having 3-5 years as a Physician Reviewer/Advisor with a third party leveling and/or appeals agency preferred. Previous utilization management, case management or peer review documentation experience in hospitals or health plans. preferred. 5 years of Clinical Hospital Experience, preferred. 5 years of experience in Internal Medicine providing direct patient care preferred. Knowledge of MCG Guidelines, preferred. Experience with Allscripts/Cerner, preferred.

Education:Graduated from an accredited Medical School, required. MD with Board eligibility, required.

Licenses / Certifications: current Unrestricted MD License to practice medicine. Board Certified by the American Board of Medical Specialties (ABMS) or the American Board of Osteopathic Specialties (ABOS) preferred.

Other:

Has the ability to travel among the WMC HEALTH NETWORK hospitals on a regular basis.