Position Description

POSITION DESCRIPTION

Physician Advisors (PA) are a key members of UWMC's provider team and are charged with meeting the organization's goals and objectives for assuring the effective, efficient utilization of health care services. The PA is a physician serving the hospital through teaching, and advising fellow providers, the Care Coordination (CC) and Utilization Management (UM) departments, and hospital leadership. The PA shall develop expertise on matters regarding physician practice patterns, over- and under-utilization of resources, medical necessity, levels of care, care progression, denials management, compliance with governmental and private payer regulations, appropriate physician coding and documentation requirements.

PRIMARY SCOPE OF SERVICE

The PA works closely with the medical staff leadership, the entire medical staff, including resident physician house staff, Care Coordination, and UM 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 hospital length of stay (LOS). This includes 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.

PAs report to the appropriate Associate Medical Director for Patient Progression and Care Coordination and/or lead PA(s).

PRIMARY RESPONSIBILITIES

The below matrix outlines current intended responsibilities for the PA role, along with an estimate of the amount of time dedicated to each function. Priorities are designed to emphasize key functions to be completed in support of status management, and hospital operations. Note that the time estimates may vary. The distribution of activities below represent current expectations, but may shift over time.

UTILIZATION MANAGEMENT 70%

Denial and Appeal Management

• Conduct concurrent peer-to-peer reviews with payors
• Determine whether to accept the denial/downgrade
• Collaborate with UM Nurse to ensure complete and timely documentation
• Support payor contracting efforts as needed, based on denial trends
• Review cases that indicate a need for issuance of a Hospital Issued Notice of Non-Coverage (HINN) or other compliance letters. Discuss the case with the attending physician and if additional clinical information is not available, discuss the process for issuance.
• Identifies and assists in development of action plans to address patterns of inappropriate status determination

Initial Reviews

• Work with Care Coordination and the attending physician to review admissions and make recommendations on status for cases that do not meet initial admission screening criteria (i.e., XSOLIS, MCG)
• Provide education to providers regarding status, LOC & length of stay (LOS)
• Seek additional clinical information from the attending and consulting physicians when indicated. Recommend and request additional, or more complete, medical record documentation to better support assigned status.
• Facilitate pre-payment reviews and/or participating in recovery audit contractor reviews

Continued Stay Review

• Using Epic and/or XSOLIS, review all extended OBS, conflict OBS and IP, and review plan with Care Coordination and the attending as needed for conversion or discharge facilitation
• Review case and discuss with attending physician as necessary following CC escalation, e.g.
  • Request further information from the physician to ensure documentation supports the patient the appropriate status or LOC, or assist in creating a discharge plan
  • Increase awareness of proper documentation requirements

Other

• Identifies and escalates trends of concern in above areas

CDI 25%

• Follow-up on unanswered CDI queries
• Ensure completion and facilitation of missing information in operational reports
• Provide feedback and education on clinical documentation using specific case examples
• Facilitates development of query templates
• Facilitates development of Epic templates to support appropriate documentation
• Performs Readmission reviews on patients readmitted within 7 days of discharge to identify reasons for avoidable readmission, and to assist in identification of whether readmission is unrelated to index stay

EDUCATION, GOVERNANCE, SUPPORT 5%

• Maintain current of federal, state, and payor regulatory and contract requirements, and educate staff on these requirements.Participate quarterly meetings with the Lead CMP and Medical Directors to provide an Executive Summary of mutually agreed upon reviews. Present outcomes at UM Committee
• Attend continuing education sessions pertaining to UM and Quality
• Assist in implementation of new regulatory guidelines
• Educate other physicians regarding payor requirements

ADDITIONAL EXPECTATIONS AND RESPONSIBILITIES

• Conduct presentations to Medical Staff, Hospital Board/Administration as warranted as may be related to PA areas of expertise or knowledge
• Assist with the evaluation of the hospital UM program, including adherence to the required CMS Conditions of Participation

OUTCOMES AND DELIVERABLES:

• Submits monthly record of performance metrics or data as requested to the medical directors (or direct report)
• Maintains documentation of the number of interventions and resulting outcomes or decisions
• Documents education sessions for medical staff on trends, practice patterns, or relevant information
• Tracks and reports appeal and denial results where CMP intervention was required

DISCLAIMER

This job description is designed to describe the general nature and level of work performed by employees within this classification. It is not designed or to be interpreted as a comprehensive inventory of all duties and responsibilities required of employees assigned to this job.

FACULTY APPOINTMENT AND SALARY

PA Program Medical Director role is a 50% FTE position. This position will have a full or part-time faculty appointment in one of the UWSOM departments appropriate for background and experience. This is a 12-month service period position (July - June) with an anticipated start date of May 1, 2024.

The base salary range for this position at 100% FTE (prorated to actual FTE) will be $19,702 to $40,292 per month, commensurate with experience and qualifications, or as mandated by a U.S. Department of Labor prevailing wage determination. Other compensation associated with this position may include an administrative salary supplement (ADS), and incentive through UW Physicians (UWP) practice plan.

For practitioners holding an appointment in one of the physicians practice plans, see the link for additional benefits that may be available.

For UWP: https://faculty.uwmedicine.org/wp-content/uploads/2019/09/UWP-Benefits-Summary-for-recruitingef-edits-v3.pdf

Qualifications

MINIMUM REQUIREMENTS

Licensure:

• Hold and maintain an unrestricted medical license in the state of Washington
• Meet the requirements (and become a member) of the Hospital medical staff

Experience:

• 5 years clinical experience in hospital-based practice, strongly preferred
• Possess or acquires a solid foundation, knowledge, and/or experience in the areas of utilization management, quality improvement, and patient safety, required
• Possess expertise on matters regarding physician practice patterns, over- and under-utilization of resources, medical necessity, levels of care, care progression, denials management, compliance with governmental and private payer regulations, appropriate physician coding and documentation requirements

Education:

• Doctor of Medicine, Doctor of Osteopathic Medicine, or foreign equivalent, required.
• Strong computer skills and working knowledge of Epic
• Ability to build rapport and collaborate with medical staff and hospital leadership
• Demonstrated business and financial acumen
• Knowledge of regulatory compliance
• Familiarity with MCG placement status criteria

In order to be eligible for university sponsorship for an H-1B visa, graduates of foreign (non-U.S.) medical schools must show successful completion of all three steps of the U.S. Medical Licensing Exam (USMLE), or equivalent as determined by the Secretary of Health and Human Services.

PREFERRED QUALIFICATIONS

• Experience in working with CMS and RAC Denials
• Knowledge of regulatory compliance
• Familiarity with MCG placement status criteria'
• Board Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP)
• Physician Advisor sub-specialty Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP)

Instructions

Equal Employment Opportunity Statement

University of Washington is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, national origin, sex, sexual orientation, marital status, pregnancy, genetic information, gender identity or expression, age, disability, or protected veteran status.

Benefits Information

A summary of benefits associated with this title/rank can be found at https://hr.uw.edu/benefits/benefits-orientation/benefit-summary-pdfs/. Appointees solely employed and paid directly by a non-UW entity are not UW employees and are not eligible for UW or Washington State employee benefits.

Commitment to Diversity

The University of Washington is committed to building diversity among its faculty, librarian, staff, and student communities, and articulates that commitment in the UW Diversity Blueprint (http://www.washington.edu/diversity/diversity-blueprint/). Additionally, the University's Faculty Code recognizes faculty efforts in research, teaching and/or service that address diversity and equal opportunity as important contributions to a faculty member's academic profile and responsibilities (https://www.washington.edu/admin/rules/policies/FCG/FCCH24.html#2432).

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Disability Services

To request disability accommodation in the application process, contact the Disability Services Office at 206-543-6450 or dso@uw.edu.