The Physician Advisor is aÂ key member of the CHRISTUS health leadership team and is chargedÂ with meeting the organizationâ€™s goals and objectives for assuring the effective,Â efficient utilization of health care services. The Physician Advisor is a â€‹physician serving the hospitalÂ through teaching, consulting, and advising the care management and utilizationÂ review departments and the hospital leadership. The Physician Advisor shallÂ develop expertise on matters regarding physician practice patterns, over andÂ under-utilization of resources, medical necessity, levels of care, care progression, denial management, compliance with governmental and privateÂ payer regulations, appropriate physician coding and documentation requirements.
The Physician Advisor works closely with the medical staff leadership, the entire medical staff, including resident physician house staff, all areas of resource management, case management, social services, discharge planning, and utilizationÂ management to develop and implement methods to optimize use of hospital services for all patients while also ensuring the quality of care provided. This includes working with hospital leadership in developing care management protocols with physicians and others to optimize length of hospital stay and efficient management of resources, insuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities.Â
Reviews medical records of patients identified by care managers or as requested by the healthcare team and in accordance with the hospitalâ€™s established Utilization Management plan 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 reviews of patients
Determine if professionally recognized standards of quality are met
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.
Communicates with physicians regarding CDI query response and clinical documentation recommendations.
Recommends next steps in coordination of care and evidence-based medicine indicators.
Understands and applies general utilization review guidelines/criteria while balancing this information with medical judgement to ensure a complete review and recommendation for level of care.
Supports care management functions in a data-driven approach.
Notifies the care manager of any conflict of interest in reviewing a particular patient record and assists in identifying an alternate physician to review such record.
Acts as a liaison with payers to facilitate approvals and prevent denials.
Facilitates, mentors, and educates other physicians regarding payer requirements.
Reviews long length of stay patients in conjunction with the care management team, and other members of the multidisciplinary team to facilitate the most appropriate utilization of resources.
Participates in multidisciplinary rounds with the healthcare team as indicated.
Identifies patients who are appropriate for an alternate level of care and works with physicians to facilitate referrals as needed.
Provides guidance to ED physicians and care management team regarding status issues and alternatives to acute care when acute care is not warranted.
Works with care management and interdisciplinary team to ensure appropriate continuity of care and to reduce readmissions.
Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, alternative levels of care, community resources, and end of life care. Works with physicians to facilitate referrals to the continuum of care.
Provides education to physicians and other clinicians about proper utilization of various acute care levels of care and assist in creating plans to address patients who need a different level of care.
Supports the organization in quality improvement efforts.
Assists in the development and implementation of systems and services that fully integrate care and reimbursement through outcomes-based management across the continuum of care.
Facilitates collaboration of the care management infrastructure with the medical staff to include clinical practice improvement, approaches to reengineering care and managing practice variation, as well as the rapid adoption of evidence-based medical guidelines and protocols.
Educates individual hospital staff physicians about coding guidelines 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 regarding care management, utilization review, and clinical documentation integrity initiatives.
Actively participates in hospital committees to support evidence-based medicine and optimal standards of care.
Chairs or serves on the Utilization Management committee and assists with the evaluation of the hospital utilization management program.
Maintains current knowledge of federal, state, and payer regulatory and contractual requirements.
Attends continuing education sessions pertinent to case management, utilization review, and clinical documentation integrity.
Acts as a consultant and sources to attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and appropriate use of resources.
Acts as a consultant and resource to the medical staff regarding federal and state utilization and quality regulations.
Communicates effectively across administrative and clinical lines to accomplish the necessary integration of hospital services in support of medical practice within the hospital.
Reviews cases that indicate a need for issuance of a hospital notice of non-coverage. 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.
Participates in the facility MEC as a representative of the Utilization Review Committee.
Participate in Revenue Integrity and Denial meetings as appropriate.
Additional functions as deemed appropriate and warranted.Â
Hold and maintain an unrestricted US medical license in the state of primary employment (exception for remote Physician Advisors).
Meet the requirements to be a member of the medical staff
PossessÂ or acquires a solid foundation, knowledge, and experience in the areas ofÂ utilization management, quality improvement, and patient safety.
PossessÂ a working knowledge of case management operations, administrative standards and policies.
StrongÂ computer skills and working knowledge of the Electronic Medical Record.Â
Familiarity with MCG/Interqual placement statusÂ criteria preferred.
Member of the American College of Physician Advisors (ACPA) preferred.
Board Certification and Physician Advisor Sub-specialty Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) preferred.
AbilityÂ to build rapport with medical staff and hospital leadership to obtain the buy-inÂ and collaboration necessary to achieve desired outcomes
Able to serve as a resource to the Case Management staff on medical necessity, level of care, care progression, denial management, and resource utilization as well as liaison to the Medical Staff for Case Management operations.Â
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.