Physician Advisor - Utilization Management

Physician Advisor

The Physician Advisor (PA) is a key member of the hospital's leadership team charged with meeting the organization's goals and objectives for ensuring the effective, efficient utilization of health care services. The PA will develop expertise on matters regarding physician practice patterns, over- and under-utilization of resources, medical necessity, documentation best practices, level of care progression, denial management and compliance with governmental regulations and conditions of participation and commercial insurance contracts. The PA is responsible for establishing, maintaining and strengthening the relationship with System Enterprise and the hospital to appropriately optimize the use of Sutter Health Internal Physician Advisor Services (IPAS). The physician Advisor will work closely with the medical staff, including house staff, and all utilization management (UM) personnel, Care Management (CM) personnel to develop and implement methods and strategies to optimize the use of hospital services. This includes care management processes that ensure patients are in the appropriate level of care with supporting documentation of regulatory compliance and accurate coding. The Physician Advisor (PA) conducts clinical reviews on cases referred by UM/CM staff and or other healthcare professionals to meet regulatory requirements in accordance with the hospital objectives for assuring quality patient care and effective, efficient utilization of health care services. The PA meets with care management, UM staff and health care team members and medical directors of third-party payers to discuss the needs of patient's and alternative levels of care. The PA acts as consultant to and resource for attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources. The PA will act as a liaison between the CDI (Clinical Documentation Improvement) professional, HIM (Health Information Management ), and the hospital's medical staff to facilitate accurate and complete documentation for coding and abstracting of clinical data, capture of severity, acuity and risk for mortality, in addition to Direct Report Groups (DRG) assignment.

EDUCATION: Doctorate: Graduate of an accredited medical school CERTIFICATION & LICENSURE: MD-Doctor of Medicine OR DO-Doctor of Osteopathy Unrestricted medical license in state of residence TYPICAL EXPERIENCE: 3 years of recent relevant experience.

SKILLS AND KNOWLEDGE: Excellent interpersonal communication and negotiation skills. A broad knowledge base of health care delivery and case management within a managed care environment. Comprehensive knowledge of Utilization Review, levels of care, and observation status. Some awareness of healthcare reimbursement systems: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Patient Processing Service (PPS), Centers for Medicare and Medicaid Services (GR) Grouper (CMS) preferred. Post-acute levels of care such as Home Health, Hospice, Advance Illness Management (AIM), and Palliative Care. Skilled Nursing Facility (SNF), Long Term Acute Care (LTAC), B&C, Sub-acute, Acute rehab. Proficient Knowledge of coding and DRG assignment process preferred. Must be able to effectively communicate with, and promote cooperation and collaboration between individuals including patients/families/caretakers, physicians, nurses and other ancillary partners. Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families. Demonstrates commitment to service excellence in all patient, family and employee interactions and in performing all job responsibilities. Functions in a manner to promote quality patient care and assure a positive patient experience. Excellent verbal and written communication skills. Must have excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities. Intermediate computer skills. Ability to promote teamwork and to effectively function in teams. Ability to interact effectively with key internal and external constituents using collaboration, and customer service skills that promote excellence in the patient experience.