Physician Advisor/UM/CDET

Reports through the CFO with collaborative reporting relationships with the Executive Director, Case Management, and the Chief Clinical Officer, Beacon Health System. The Physician Advisor (PA) conducts clinical reviews on cases referred by case management staff and/or other health care professionals to meet regulatory requirements and in accordance with the hospitals objectives for assuring quality patient care and effective, efficient utilization of health care services. The PA meets with case management and health care team members to discuss selected cases and make recommendations for care, interacting with medical staff members and medical directors of third party payers to discuss the needs of patients 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 further acts as a resource for the medical staff regarding federal and state utilization and quality regulations. As the CDI physician advisor, the PA will 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, capture of severity, acuity and risk of mortality, in addition to DRG assignment. The PA also supports community case management efforts providing medical case review to contribute to the overall plan for care along with other members of the health care team.MISSION, VALUES and SERVICE GOALS

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Care Management Function Support

• Reviews medical records of patients identified by case managers or as requested by the healthcare team in order to: Assist with level of care and length of stay management. Assist with the denial management process. Review and make suggestions related to resource and service management. Assist staff with the clinical review of patient, including those in post hospital case management programs. Determine if professionally recognized standards of quality care are met.
• Reviews cases that indicate a need for issuance of a hospital notice of non-coverage/Important Message from Medicare. Discusses the case with the attending physician and if additional clinical information is not available, discusses the process for issuance and appeal to the physician.
• Documents patient care reviews, decisions, and other pertinent information. Understands and uses InterQual or Milliman criteria. Documents response to case management referrals. Supports Case Management in a data-driven approach.
• Acts as a liaison with payers to facilitate approvals through conducting peer to peer case reviews for denial prevention when allowed under payor policy. Facilitates, mentors, and educates other physicians regarding payer requirements.
• Participates in review of long stay patients, in conjunction with the Case Management Leadership, care team and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care. Participates in patient rounds with the Healthcare Team as indicated.
• Works with Care Management and an interdisciplinary team to ensure appropriate continuity of care and to reduce readmissions.
• Leads hospitals Utilization Management Committees to support the Case Management function, revenue integrity, and effective resource utilization.

Physician Support and Education

• Acts as a Physician Advisor to the Medical Staff providing education regarding patient status determinations and peer to peer conversations with insurers.
• Provides feedback to attending and consulting physicians regarding level of care, length of stay, and quality issues. Seeks additional clinical information from the attending and consulting physicians. Recommends and requests additional, more complete, medical record documentation. Recommends next steps in coordination of care and evidence-based medicine indicators.
• Serving as a Hospital liaison with regards to case management representing the Hospital while attending any medical staff meetings.
• Serving on various committees, task forces, and special project teams of the Medical Staff at their request.
• Provides medical case review to contribute to the overall plan for care for community care coordination patients along with other members of the health care team.

Process Improvement

• Identifies quality, safety, patient satisfaction and efficiency issues leading to suboptimal care. Takes appropriate action to resolve.
• Promotes and educates healthcare team on a team approach to patient care. Promotes coordination, communication and collaboration among all team members.
• Supports the organization in quality improvement efforts requiring physician input and/or involvement.
• Involved in various hospital committees as indicated including Ethics.
• Actively participates in Hospital committees to develop protocols related to evidence based medicine and supports optimal standards of care.
• Assists in the development of metrics and collection and communication of information obtained to assist in ongoing performance improvement and monitoring.

Clinical Documentation Support

• Advises the CDI professional, HIM, and the hospital's medical staff to facilitate processes to support accurate and timely completion of documentation for coding and abstracting of clinical data, capture of severity, acuity and risk of mortality, in addition to DRG assignment
• Assist in the processes of improvement to enhance communication at transitions of care between clinical providers.
• Educates individual hospital staff physicians about ICD coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records.
• Educates specific medical staff departments at departmental meetings regarding: Reasons why individual physicians should be concerned about correct disease reporting and the subsequent ICD code capture of severity, acuity, risk of mortality, and DRG assignment, such as Physician performance profiling, Physician E&M payment and pay for performance, appropriate hospital reimbursement and profiling for patient care. Ways to provide improved health record documentation that specifically affect ICD code assignment capture of severity, acuity, risk of mortality, and DRG assignment.

Contributes to overall effectiveness of the organization and departments

• Maintains current knowledge of federal, state, and payer regulatory and contract requirements.
• Attends continuing education sessions pertaining to utilization, quality management, care coordination/case management and physician advisor role.
• Additional functions as deemed appropriate and warranted.

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:

• Leverage innovation everywhere.
• Cultivate human talent.
• Embrace performance improvement.
• Build greatness through accountability.
• Use information to improve and advance.
• Communicate clearly and continuously.

Education and Experience

• The knowledge, skills and abilities as indicated below are normally acquired through successful completion of a Doctor of Medicine Degree. A license to practice medicine in the State of Indiana, membership in the organized medical staff and prior experience in medical staff affairs and utilization review/case management are required. Certification through the American Board of Quality Assurance and Utilization Review Physicians is preferred.

Knowledge & Skills

• Demonstrates the leadership skills necessary to support the case management function.
• Demonstrates a proactive, results oriented approach to achievement of goals.
• Demonstrates sound problem solving and decision making ability.
• Demonstrates the ability to plan, organize work, and manage time and meeting commitments.
• Demonstrates the interpersonal and communication skills (both verbal and written) necessary to articulate ideas clearly and concisely, to make effective presentations, to develop and maintain positive working relationships, and to interact effectively in sensitive and/or complex situations with a wide range of internal and external contacts.

Working Conditions

• Works in an office environment.

Physical Demands

• Requires the physical ability and stamina to perform the essential functions of the position.