Roles and Responsibilities Overview The Physician Advisor-Care Management and Clinical Documentation Improvement (PACM) is a full-time administrative physician role serving Good Shepherd Hospital - Longview and its affiliates through teaching, consulting, and advising both the Care Management Department and the medical staff on matters regarding physician practice patterns, documentation, over- and under-utilization of resources, medical necessity, compliance rules and regulations, collaboration and relationships with payers, and the community. The PACM also ensures physician support and execution for the Care Management and CDI Departments' initiatives by promoting effective and efficient physician documentation to support the patient's Level of Care (LOC), billing status, and appropriateness of Medicare Severity-Diagnosis Related Group (MS-DRG)/DRG assignment. The PACM will submit monthly time records documenting time actually spent in the provision of the responsibilities outlined below.
Professional Qualifications The Physician Advisor-Care Management and Clinical Documentation Improvement role should be staffed by a physician with the following qualifications:
·Licensed physician in state of residence
·Certified by the American Board of Quality Assurance and Utilization Review Physicians, Inc (ABQUARP) - preferred
·Experienced in clinical practice with understanding of utilization review
·Served on or chaired a Utilization Management committee
·Demonstrated cost efficient practice
Physician Advisor - Care Management & CDI Duties and Responsibilities
Utilization Management Plan: 20%
·In collaboration with the Director of CM, lead the Utilization Review Committee
·In collaboration with the Director of CM, monitor key metrics for UM and participate in action steps to achieve targets. Metrics include (but not limited to):
·Denial trends, appeals & recoveries
·Length of stay- inpatient and observation
·Condition Code 44
Physician & Staff Education: 15%
·Provide education to physicians and other clinicians related to regulatory requirements, appropriate billing status and utilization of alternate levels of care, community resources, and end of life care.
·Work with physicians to facilitate referrals to the continuum of care
·Facilitate, mentor, and educate other physicians regarding payer requirements
·Provide mentoring/coaching to UR Case Managers to increase knowledge in care progression
·Educate physicians on the benefits and importance of a clinical documentation program and how to work with CDI specialists
Care Management: 50%
·Participate in daily IDRs takes action to expedite testing and treatment to promote efficient patient care and appropriate LOC
·Provides guidance/assistance to the Emergency Department Physicians and CM staff to assure correct LOC designation at intake
·Act as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate
·Participate in review of long stay patients escalated from Care Management to facilitate the use of the most appropriate LOC
·Review cases that indicate a need for issuance of a hospital notice of non-coverage determination. Discuss the case with the attending physician and if additional clinical information is not available, discuss the process for issuance and appeal with the physician.
·Document patient care reviews, decisions, and other pertinent information per hospital policy
·Possess foundational knowledge of InterQuale criteria
·Participate in Care Management Leadership & staff meetings to help identify and progress toward departmental goals
·Notify the Care Manager of any conflict of interest in reviewing a particular patient record. Assist with identifying a physician to review such record.
Clinical Documentation Integrity 15%
·Provide feedback to physicians in each service on clinical documentation using specific case examples/3M
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.