The Physician Advisor provides clinical direction and leadership to the organization, increasing its ability to produce best practice patient outcomes grounded in quality, legal, ethical, regulatory, and reimbursement parameters. As a peer to physicians and a consultant to Case Management and administration, intervenes when practice patterns or behaviors create disparity between pathway standards, intensity of service, severity of illness, patient and family rights, teamwork, or other issues regarding the stewardship of resources for individual patients and diagnostic populations.

Job Responsibilities

Include, but are not limited to:

• Works with the Executive Team to set agendas, priorities, and review/revise objective and subjective targets in cost, quality, and satisfaction.
• Leads or co-leads with the Case Management Department Leaderthe Utilization Review Committee and coordinates its activities with other key committees
• Provides medical and professional staff with education regarding denials, DRG LOS, level of care downgrades, readmission reduction, clinical documentation guidelines and utilization review regulatory requirements.
• Provides timely and effective consultation to case management team members, including concurrent assessment of the clinical situation, actions to address identified issues and necessary follow-up. Expedites communications of recommended interventions to Case Managers, Utilization Review, Social Works, physicians, and others involved in caring for individual patients whose case has been referred for consultation.
• Appeal either in writing or peer-to-peer denial or level of care downgrades or readmission denials. Adjudicates level of care decisions (observation verses in-patient) render decisions regarding CMS down grades (Code 44) or termination of benefits.
• Serve as subject matter experts to physicians and others regarding immediate or planned decisions when overt quality, ethical, regulatory, and/or financial risks may be incurred.
• Leads or co-leads hospital-wide Complex Care Rounds in accordance with established organization policy and procedure.
• Serves as an expert clinical resource on development and utilization of established clinical guidelines, order sets, pathways, and other structured care methodologies.
• Facilitates or leads quality improvement of performance improvement projects
• As requested, participates in the identification of opportunities for the organization to increase market share, flow and capacity, disease management support of populations, obtain grants, etc.
• Documents according to policy.