Job Purpose
The Physician Advisor provides physician-to-physician reviews, clinical guidance, education and escalation support while promoting evidence-based practices and appropriate resource utilization.
Duties & Responsibilities
- Conduct physician-to-physician reviews for medical necessity, level of care and denial prevention/appeals
- Support utilization review and case management teams with complex clinical decision-making
- Communicate with Physician Advisory team, hospital physicians, care coordination and utilization management staff to encourage best practices for evidence-based care and documentation
- Assist in improving documentation related to ICD coding, severity of illness, risk of mortality, and DRG assignment
- Keep abreast of current CMS and MCG evidence-based guidelines to enable utilization management decisions
- Maintain compliance with legal, regulatory and accreditation requirements and payor partner policies
- Meet productivity and quality standards within established time requirements
- Attend required training and meetings
- Participate in peer review process as needed
- Other duties as assigned
- Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
- Understand and comply with Information Security and HIPAA policies and procedures at all times
- Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties
Qualifications
- MD or DO with an active, unrestricted medical license
- US Board Certified in a recognized specialty
- Minimum of 1 year of payor or provider-side utilization review or active ACPA and/or ABQUARP certification
- Basic technical skills with hospital EMRs a must
- Strong knowledge of utilization management, medical necessity and payer regulations
- Familiarity with MCG/InterQual placement status criteria is preferred
- Member of the American College of Physician Advisors (ACPA) preferred
- Able to effectively present information, both formal and informal
- Proficiency in Microsoft Office Suite
- Strong interpersonal skills, ability to communicate well at all levels of the organization
- Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
- High level of integrity and dependability with a strong sense of urgency and results oriented
- Excellent written and verbal communication skills required
Working Conditions
- Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes
- Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear
- Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress
- Work Environment: The noise level in the work environment is usually minimal
Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.
