The Physician Advisor is a key member of the NGHS Revenue Cycle team and is charged with meeting the organization's goals and objectives for assuring effective, efficient, and compliant utilization of health care services. The role includes significant educational and supportive services, working with providers and hospital staff. The Physician Advisor shall develop expertise on matters regarding physician practice patterns, over and under utilization of resources, medical necessity, levels of care, care progression, denial management, compliance with governmental and private payor regulations, and documentation requirements. The role works closely with the entire medical staff, including resident physician house staff, all areas of resource management, Utilization Management and Case Management to develop and implement methods to optimize use of hospital services for all patients while also ensuring the quality of care provided. Concurrent communication with medical staff will be crucial to ensure timely documentation in the medical record, to include status orders that reflect the appropriate level of care.

Job Specific and Unique Knowledge, Skills and Abilities

• Working knowledge of the Revenue Cycle processes and goals.

• Excellent customer service and interpersonal skills. Able to effectively present information, both formal and informal.  Strong written and verbal communication skills with all levels of internal and external customers.  

• Persuasiveness and leadership to obtain action, consent, agreement, or approval. May involve difficult negotiations or a high degree of diplomacy and judgement to achieve results.

• Requires an innovative, creative thinker to initiate long range programs, goals, policies and procedures. Ability to foresee and assess potential problems and to plan alternative solutions. Strong analytical skills.

• Strong organizational skills and ability to set priorities and multi-task, demonstrates flexibility, teamwork, and is accustomed to change in the healthcare environment.   

• Demonstrates ability to drive results and produce outcomes.

• Working knowledge of criteria for Medicare, Medicaid, HMO and private insurance coverage; knowledgeable of Federal and State regulations and hospital finance.

• Ability to work collaboratively; ability to network and access resources as needed by team.

• Obtains familiarity and working knowledge of standard published criteria such as InterQual/MCG and applies professional judgement and patient specific variables as may be necessary of justifiable.

• Functions with little direct supervision in accordance with the goals set forth by Administrators and Department Directors.  
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Essential Tasks and Responsibilities

• Participation and active role in the Utilization Review Committee to include review of data related to utilization and presentation of findings with recommendations for improvement.

• Support physician education and collaboration, including but not limited to the following: Provide education to physicians and other clinicians related to regulatory requirements, appropriate utilization of hospital services, community resources and alternative levels of care. Create action plans to address issues. Provide concurrent physician coaching and on-going education on appropriate documentation to support level of care and care standards. Provide regular feedback to physicians and all other stake holders regarding level of care, length of stay and potential quality issues. Facilitate, mentor, and educate other physicians regarding payer requirements. Contacts physicians in a timely manner to resolve delays and achieve positive outcomes. Demonstrates positive outcomes through interventions with attending or consulting physicians that impact status determination, delay care and affect LOS, or avoidable days. Participates in Medical Staff education on Healthcare Payment Models as needed, including value based purchasing, clinically integrated care, bundled payments. Identifies denial trends and works with the medical staff and administration to resolve the issue.

• Supports the Utilization Review process through second level reviews as needed and in a timely fashion. These include, but are not limited to: status reviews, condition code 44 second level reviews, compliance short stay reviews, surgery precert compliance, compliance with inpatient only procedures, continued stay reviews, HINN issuance. Assists in 2 midnight rule compliance.  Works collaboratively with physicians and advanced health practitioners based on results of these reviews, to include gathering additional information, coaching to facilitate documentation that supports the level of care and timely discharge as indicated. 

• Provides consultation to UR nurses and CM staff regarding complex clinical issues impacting length of stay, medical necessity and discharge transition

• Assist with length of stay management and utilization of resources

• Active participation in denials management processes to include peer to peer discussions, case review and appeal writing, physician education in denial occurances and prevention, metric tracking and presentation.   

• Develops and maintains successful relationships within the payor community

• Active participant in Complex Case Review, providing input on length of stay and transition of care opportunities

• Assists in governmental regulation compliance through research, reviews, and education.  Serves as active member of Acute/Post Acute Compliance Committee.  

• Participates in payor contract development and negotiation processes as requested.  Provides input on utilization and precertification components based on experience with payors

• Identifies documentation opportunities through clinical/medical necessity reviews along with denial/appeal work.  Drives documentation improvement strategies and works directly with providers to make improvements.   

• Performs other duties and tasks as assigned.  

Minimum Job Qualifications

• Licensure or other certifications: Hold an unrestricted medical license in the state of Georgia.   

• Educational Requirements: Medical Degree, Board certification required

• Minimum Experience: Five (5) - seven (7) years physician practice experience, 10+ preferred. Possess or acquire solid foundation, knowledge an/or experience in areas of Utilization Management and Quality Improvement. Possess working knowledge of UR operations, along with standard UR metrics and payor methodologies. Experience and knowledge in healthcare Federal and State regulations is required. Strong computer skills and working knowledge of the EMR required.  

Preferred Job Qualifications

• Preferred Educational Requirements: Member of the American College of Physician Advisors (ACPA).

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About Northeast Georgia Health System (NGHS)

Northeast Georgia Health System (NGHS) is a not-for-profit community health system anchored by five NGMC hospital campuses and a Level I Trauma Center, all dedicated to our mission to improve the health of our community. We believe that your next role is more than just a job; it’s a major life decision. NGHS fosters a working culture for more than 1,400 medical staff members representing 60+ specialties that prioritizes professional development, career advancement and access to leading technology. Discover how NGHS can support the life you choose to live.

Connections working at Northeast Georgia Health System (NGHS)

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