At Houston Methodist, the Physician Advisor is responsible for teaching, consulting, and advising the case management department, clinical documentation specialists, medical staff, and the hospital on matters regarding medical necessity; compliance rules and regulations; collaboration and relationships with payers; physician practice patterns; documentation and over- and under-utilization of resources. The Physician is a key member and leader of the hospital's utilization review/management committee, which is charged with regulatory goals of ensuring high levels of healthcare quality and acceptable levels of cost. The Physician Advisor will conduct clinical reviews on cases referred by case management and/or other healthcare professionals in accordance with hospital objectives related to quality care of patients.
PEOPLE ESSENTIAL FUNCTIONS
- Interact with medical staff members to discuss needs of patients and alternative levels of care. Provide consultation to case management staff regarding complex clinical issues and advises on next steps. Provide feedback to attending and consulting physicians regarding level of care, length of stay, and quality issues.
- Chair the utilization review/management committee, actively participates in defining operational strategic objectives for the Utilization Management Program and serve as the liaison to other medical staff committees that interface with the utilization review/management committee. Assist with the evaluation of the hospital's Utilization Management Program, including annual review and revision of the hospital's UR plan.
- Contacts physicians to resolve delays and achieve positive outcomes and ensures physician accountability for efficient patient care management. Communicates to medical staff leaders (e.g., department chairs, medical directors and other attending physicians as necessary) relevant findings of physician's performance when patterns of clinical outcomes demonstrate undesirable variation.
SERVICE ESSENTIAL FUNCTIONS
- Create strategies to enhance hospital and post-acute interdisciplinary efforts for maximizing patients/family outcomes. Serve as an advocate for case management services and clinical documentation. Collaborate with medical staff in the development and measurement of performance standards involving patient care and utilizations of resources to achieve optimal outcomes.
- Round on the patient care units, and throughout the hospital, to identify opportunities, to impact resource utilization and manage length of stay (e.g., outliers, medical management practices, problematic patient/family dynamics).
- Provides support and assists Clinical Documentation Specialists and Coders on an ongoing basis by addressing specific documentation issues encountered by CDSs/Coders, including noncompliant physicians. Determines the focus of presentations of clinical examples regarding documentation opportunities and specifics based on quarterly trends and presents this information in department meetings.
QUALITY/SAFETY ESSENTIAL FUNCTIONS
- Act as consultant and resource to attending/responsible physicians regarding their decisions relative to appropriateness of hospitalization, continued stay and use of resources in length of stay management. Use InterQual criteria and document patient care reviews, decisions, and other pertinent information per hospital/case management and clinical documentation policies.
- Review issues identified by case management department to ensure appropriate follow-up, recommends improvement initiatives as needed and makes referrals to appropriate department chairs as necessary.
- Determine if standards of quality care, as defined by the hospital's Medical Executive Committee are met.
- Seek additional clinical information from the attending and consulting physicians as required to make effective level of care determinations, and in doing so, recommends and requests additional, or more complete, medical record documentation to support such determinations.
FINANCE ESSENTIAL FUNCTIONS
- Review medical records identified by case managers, or as requested by other members of the healthcare team, in order to assist with the identification and management of denials. Make suggestions related to resource utilization and service management.
- Actively participate in the hospital's claim denial process, including, but not limited to, responding to denials from payers on a concurrent basis; authoring denial letters as needed on retrospective denials; and determining to what extent denied cases will be appealed. Review cases that indicate need for issuance of a hospital notice of non-coverage.
GROWTH/INNOVATION ESSENTIAL FUNCTIONS
- Maintain knowledge of current state, federal, and CMS regulations, DNV requirements, and guidelines on case management, utilization review, and clinical documentation.
- Provide ongoing education to physicians and other providers on the link between ICD-10 and clinical terminology to improve understanding of severity of illness, risk of mortality and DRG assignments of their individual patient records, as these relate to individual physician/provider scorecards and collective (e.g. division, department, entity specific) quality profiling and reimbursement. Education may include department or division meetings, individual provider meetings, articles in entity-specific newsletters and other communication vehicles as identified/developed.
- Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization of alternate levels of care and community resources. Works with physicians to facilitate referrals across the continuum of care. Facilitates, mentors, educates other physicians regarding payor requirements and lnterQual Criteria and CMS guidelines for medical necessity.
This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
EDUCATION
- Graduate of accredited medical school
WORK EXPERIENCE
- Five years recent experience in clinical practice.
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