Description

Summary:

Provides physician leadership and expertise related to appropriate utilization/level of care (LOC) and appropriate clinical documentation. Provides oversight for other Physician Advisors for both the centralized denial prevention unit and the local hospitals. Collaborates with appropriate departments, leaders and committees to meet established goals for physician participation and compliance with expectations.

Responsibilities:

1. Provides physician leadership for physician advisors and physicians throughout the organization.
2. Manages processes, policies, workflows and overall management of the physician advisor role within the organization.
3. Works to lead standardization of policy, procedure and approach to physician advisor roles in utilization management, , documentation and denials/downgrades.
4. Serves as physician expert and provides support to care team and denial prevention and denial management team members regarding utilization decisions including screening for appropriateness of hospitalization, LOC status, LOS management, continued stay decisions, clinical review of patients, utilization review activities, resource utilization/management, denial management issues, and potentially quality issues.
5. Functions as a consultant and resource to other Physician Advisors and primary (attending) physicians.
6. ;Assists Denial Prevention and Denial Management teams with complex cases requiring Physician Advisor expertise to support both peer to peers as well as creation and/or review of appeal letters to overturn retrospective denials.
7. Supports care team to ensure appropriate patient placement, care/discharge/etc.
8. Ensures medical staff have understanding and compliance with applicable areas of expertise.
9. Provides instructional input and education to medical staff as appropriate.
10. Maintains knowledge of regulatory and accreditation requirements related to utilization review (UR) LOC and clinical documentation.
11. Conducts verbal and written Peer to Peer reviews to assist with appeals of denied or downgraded coverage determinations by managed care, commercial payers, and recovery audit contractors.
12. Maintain and Model the organization's values
13. Demonstrates regular, reliable and predictable attendance
14. Performs other duties as required

Other Information:

Education Skills Experience

• Minimum Education/Training Required: Graduate of an accredited medical school.
• Completion of specialty residency (e.g., Internal Medicine, Emergency Medicine)
• Board Certified/Eligible Physician licensed in the applicable states
• American College of Physician Advisors (ACPA) certification preferred
• Five years recent experience in clinical practice in a hospital strongly preferred
• Previous experience as a physician advisor preferred
• Experience with participation in medical staff committees preferred
• Current active medical staff privileges
• Demonstrated knowledge of clinical, quality, and administrative facets of the healthcare industry.
• Strong clinical acumen; Knowledge of Care Management/Utilization Review principles, processes, and their practical application.
• Working knowledge of third-party payer guidelines/medical necessity criteria (e.g., knowledge of admission criteria for all levels of care)
• Understanding of approaches to denials management
• Familiarity with clinical documentation requirements
• Working knowledge of Centers for Medicare and Medicaid Services rules and regulations, and interest in building this knowledge through experience and partnership with Care Management
• Excellent communication and presentation skills (both written and oral)

Working Conditions:

Manual: Some manual skills/motor coord & finger dexterity

Occupational: Little or no potential for occupational risk

Physical Effort: Sedentary/light effort. May exert up to 10 lbs. force

Physical Environment: Generally pleasant working conditions

Company: Nuvance Health

Org Unit: 1768

Department: Denial Mgmt

Exempt: Yes

Salary Range: $0.00 - $1000.00 Hourly