JOB SUMMARY

The Physician Advisor collaborates with Care Managers and Attending Physicians to align on the level of care, patient billing status, and potential barriers to patient discharge. The Physician Advisor (PA) conducts clinical review of cases to ensure compliance with regulatory requirements, hospitals objectives, and quality patient care while ensuring effective and efficient utilization of resources. The Physician Advisor guides the team to improve clinical and financial outcomes with documentation and clinical education.

• Educate and supports physician documentation for appropriateness of admission and continued stay, severity, and morbidity/mortality.
• Review patient status when admission criteria is non-sufficient for admission.
• Monitor observation and the application of the 2nd Midnight across payor types (CMS regulation).
• Perform concurrent review and escalation of cases not meeting criteria.
• Provide guidance and advisory services to physicians, case managers and clinical documentation specialist regarding correct level of care and reimbursement. Apply knowledge of utilization review, discharge planning, patient status changes, length of stay, patient monitoring practices, medical necessity concepts and associated regulations in case management decisions. Assist in the identification of unnecessary testing, avoidable days, telemetry/ICU overutilization, and antibiotic stewardship.
• Deliver support associated with palliative care, end-of-life-care and hospice.
• Apply knowledge of Health Insurance and Managed Care Programs, along with values- based care, pay-for-performance programs (all payer types) and reimbursement models in decision making and reviews.
• Provide peer-to-peer payor review in collaboration with attending physicians.
• Support Recovery Audit Contractors (RAC’s).
• Assist with mitigating barriers to discharge and care progression.
• Perform concurrent review of cases greater than 4 days or the assigned/estimated GMLOS
• Partner with the care management team with the management of LOS, complex care needs and patient throughput efforts. Provide transition of care advisement.
• Support education to minimize clinical variability throughout the medical staff.
• Assist case managers with Medicare and Medicaid appeals and Administrative Law Judge (ALJ) testimonies. Act as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate. Provide telephonic and written appeals as requested for commercial payors.
• Perform reviews and appeals. (Peer-to-peer, retrospective/closed record review, concurrent appeals).
• Act as a liaison between the CDI professional, HIM, and the hospital’s medical staff to facilitate accurate and complete documentation for coding and abstracting of clinical data for: capture of severity, acuity and risk of mortality and DRG assignment. Facilitate, mentor, and educate physicians regarding payer requirements, ICD coding guidelines (e.g., co-morbid conditions, severity, acuity, risk of mortality), DRG assignments, and documentation on patient records.
• Actively participate in hospital rounds, committees etc. and in meetings related to utilization, length of stay and barriers to discharge.
• Lead discussions involving documentation, decisions on status, appropriate level of care. Help to develop a “culture of urgency” in managing hospital care often resulting in reducing resource consumption.
• Interface with the C-Suite in matters regarding metrics and requirements.
• Track and trend outcome Key Performance Indicators (KPIs) for financial and compliance best practice results. Provide individual education based on trends and regulatory changes.
• Performs related duties as assigned.