Catholic Health Initiatives Physician Advisor, Utilization Management in ENGLEWOOD, Colorado
Physician Advisor, Utilization Management
The Utilization Management Physician Advisor (PA) conducts clinical case reviews referred by casemanagement staff and/or other health care professionals to meet regulatoryrequirements and in accordance with the hospital’s objectives for assuringquality patient care and effective and efficient utilization of health careservices.
The PA meets with case management and health care team members todiscuss selected cases and make recommendations for care as well as interactingwith medical staff members and medical directors of third party payers todiscuss the needs of patients and alternative levels of care.
The PA acts as a consultantto, and resource for, attending physicians regarding their decisions relativeto appropriateness of hospitalization, clinical documentation, continued inpatientstay, and use of healthcare resources.
The PA further acts as a resource forthe medical staff regarding federal and state utilization and quality regulations.
The PA will act as a liaison between OneCare (electronic health recordcapabilities) and the medical staff ensuring that the system is optimized foreffective physician use.
The PA helps facilitate training for the physicians.
The PA must demonstrate interpersonal and communication skills and must beclear, concise and consistent in the message to all constituents.
Conducts medical record review in appropriate cases formedical necessity of inpatient admission, need for continued hospital stay,adequacy of discharge planning and quality care management.
Understand the intricacies of ICD-9-CM, ICD-10-CM/PCS,MS-DRG, APR-DRG, and the Medicare Inpatient Prospective Payment System (IPPS)to make medical determinations on severity of illness, acuity, risk ofmortality, and communicate with treating physicians in cooperation with theutilization team and health information personnel
Serve as a liaison between the national care managementteam, medical staff, and medical executives to encourage physician cooperationand understanding of documentation importance
Assist in communications of internal physician advisorservices in the hospital newsletters and other communication vehicles tofurther educate the medical staff
Communicate feedback on program results to facilityleadership (i.e. CMO, Care Management Directors, Quality Directors)
Provide feedback and education to the Care Management andClinical Documentation Departments through written and verbal communication aswell as appropriate tracking and trending for process improvement efforts.
Attend and participate in facility committee meetings, byinvitation, as applicable:
Clinical Documentation Steering Committee
Extended Length of Stay Rounds
Utilization Review Committee
Care Management Staff Meetings
Contacts Attending Physicians: Makes face-to-face and telephonic/electroniccontacts and presentations to all medical staff physicians and potentialphysician groups introducing referral services, new products and presentproduct offerings.
Conducts Peer to Peer discussions with payers as needed: Acts as a liaison and coordinator withoperations for physicians. Attends applicable committee meetings, such as aJoint Operating Committee (JOC), as requested by Utilization Management orManaged Care: Works with the Care Management Director and staff to facilitateclient profiles, clinical service utilization and support for revenuemanagement activities.
This is a work from home opportunity. You must be able to cover normal business hours M-F in the Pacific, Mountain, or Central time zone. There is some rotating on-call weekend coverage as well.
Graduate of an accredited medical school, preferably boardcertified in area of practice.
Minimum of 1 year experience as a Physician Advisorrequired, with Utilization Management experience as a member of an UM oversightcommittee.
Minimum of 5 years recent experience in clinical practice.
Solid understanding of the business and financialconsiderations of a healthcare organization, including but not limited to,excellent analytical skills, data aggregation, analysis, interpretation, andapplication.
Broad knowledge base with trust and respect of medical staffphysicians.
Additional education in quality and utilization managementthrough continuing medical education programs and self-study.
In-depth knowledge of CMS regulations in both the inpatientand outpatient arenas is required.
Broad-based knowledge regarding clinical practice, insuranceand legal disciplines, hospital operations, and revenue cycle
Knowledge of and practical use of good business English, spelling,arithmetic, practices and the ability to communicate effectively using writtenand verbal skills.
Knowledge of information technology to evaluate careeffectiveness (care process, outcomes and cost) for individual users of healthcare and patient populations
Primary Location COLORADO-ENGLEWOOD-DENVER INVERNESS
Daily Schedule Days
Scheduled Hours per 2-week Pay Period 80
Weekends Required Occasional
Req ID: 2018-R0152957