PHYSICIAN ADVISOR-UTILIZATION MANAGEMENT
Saginaw, Michigan
Employer: Covenant HealthCare
Industry: Professional
Salary: Competitive
Job type: Full-Time
Covenant HealthCare
US:MI:SAGINAW
DAY SHIFT
FULL TIME BENEFITED
Summary:
The Physician Advisor acts as a liaison between the physicians, Utilization Management (UM) and Clinical Documentation Integrity (CDI), revenue cycle and the hospital administration. The Physician Advisor works as part of a team and advises physicians and hospital staff on best practices. The Physician Advisor is responsible for remaining current regarding payer rules, CMS regulations, and hospital contractual relationships. The Physician Advisor must demonstrate excellent customer service and a positive attitude. The Physician Advisor's actions internally and with external payers must be consistent with the standards contained in the Vision, Mission and Values of Covenant HealthCare.
Responsibilities:
Maintain the denial queues.
P erform peer to peer conversations with Medicare advantage, Medicaid health plans, and commercial payers per regulatory and contractual agreements.
C onduct a primary medical necessity review on cases that are in observation status.
R eview Code 44 cases.
M aintain Physician Advisor work queue providing feedback on inpatient and observation cases.
C onduct second level medical necessity reviews for all patient cases that do not meet first level inpatient criteria.
C omplete the Medicare work queue by evaluating all short stay Medicare FFS cases for self audit and billing of Part A services.
F ollow up on query escalations.
A ssist manager with CDI/UM education.
A ssist manager with all duties otherwise unspecified.
E ngage in a collaborative work environment with department manager.
P rovides feedback to attendings and consulting physicians regarding clinical status decisions and documentation.
C ommunicates with physicians regarding escalated CDI/UM issues.
C ommunicates with the Chief Medical Officer and the MSQI committee on issues that are not resolved at a Physician Advisor to physician level.
D evelops CDI/UM huddle educational content.
C ollaborates on CDI denials.
P rovide education for physicians and APP's at educational meetings.
U tilizes appropriate criteria to assist nurses with UM case review submission.
U tilizes appropriate language for CDI query formation.
U nderstands compliant query language.
A ssist DMG with medical necessity for Clinical Review Meetings with the payers.
P rovide metric and data information to manager and director on performance of CDI/UM.
D esign and coordinate with IT and the UM technician reports and research projects for advancement of CDI/UM.
A rrange, coordinate, and facilitate the Utilization Management Committee meeting each quarter including working with the UM technician to maintain binders and minutes.
R eview HFAP/ACHC standards and changes.
P rovide constructive feedback on queries, reviews, and performance in conjunction with the manager.
P articipate in continuing education through Racrelief google groups, covenant consulting initiatives and other PA professional societies.
R emain current on regulatory changes for CMS.
R eview and distribute the new Inpatient Only Procedure List.
R eview and update the Utilization Management Committee Plan and provide a redline copy to the executive team administrative assistant for approval at committees.
R eview and work collaboratively with the Manager on CDI/UM process/policies/improvements.
E stablish relationships with lead medical directors.
Pr ovide education to the incoming CMU residents regarding CDI/UM.
P articipate in national conferences and societies on UM/CDI.
Other information:
EDUCATION/EXPERIENCE REQUIREMENTS
G raduate of an accredited medical school required.
C urrent State of Michigan medical license required.
C ompletion of a specialty residency.
M inimum of 3 years of experience in a hospital-based practice setting.
B oard certification preferred.
K NOWLEDGE/SILLS/ABILITIES
D emonstrates the ability to develop relationships .
D emonstrated ability to build rapport with medical staff and hospital leadership.
A bility to task switch and prioritize assignments based on revenue deadlines.
A bility to complete tasks by payer deadlines.
A vailable to work every other weekend and receive phone calls on emergent issues.
A vailable to work half of all holidays and receive phone calls on emergent issues.
S trong computer skills including application and use of the internet, EPIC, Excel, Powerpoint and Word.
D emonstrated ability to deliver high quality, cost-effective, efficient patient care services.
U tilization Management experience.
H ave familiarity with current medical literature, healthcare reimbursement issues (i.e. medical necessity, levels of care, coding), MCG/Inter Qual screening criteria, Medicare/Medicaid compliance, and medical staff structure, policies and procedures.
W ORKING CONDITIONS/PHYSICAL REQUIREMENTS
A bility to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.
C onstant sitting, talking, or hearing.
F requent standing, walking, lifting, carrying, and use of hands to finger, handle and feel.
F requent lift 0-25 lbs.
F requent near, far, depth perception, color vision, and field of vision.
O ccasional push, pull, balance, climbing, stooping, crawling, kneeling, crouching, taste or smell.
O ccasional lift 26-50 lbs.
NOTICE REGARDING LATEX SENSITIVITY IN APPLICANTS FOR EMPLOYMENT.
I t has been determined that Covenant HealthCare cannot provide a latex safe or latex free work environment at any of its facilities. Unfortunately, that means that any individual, including an applicant or an employee, is likely to be exposed to latex while on Covenant's premises. Therefore, latex tolerance is considered to be an essential function for any position with Covenant.
US:MI:SAGINAW
DAY SHIFT
FULL TIME BENEFITED
Summary:
The Physician Advisor acts as a liaison between the physicians, Utilization Management (UM) and Clinical Documentation Integrity (CDI), revenue cycle and the hospital administration. The Physician Advisor works as part of a team and advises physicians and hospital staff on best practices. The Physician Advisor is responsible for remaining current regarding payer rules, CMS regulations, and hospital contractual relationships. The Physician Advisor must demonstrate excellent customer service and a positive attitude. The Physician Advisor's actions internally and with external payers must be consistent with the standards contained in the Vision, Mission and Values of Covenant HealthCare.
Responsibilities:
Maintain the denial queues.
P erform peer to peer conversations with Medicare advantage, Medicaid health plans, and commercial payers per regulatory and contractual agreements.
C onduct a primary medical necessity review on cases that are in observation status.
R eview Code 44 cases.
M aintain Physician Advisor work queue providing feedback on inpatient and observation cases.
C onduct second level medical necessity reviews for all patient cases that do not meet first level inpatient criteria.
C omplete the Medicare work queue by evaluating all short stay Medicare FFS cases for self audit and billing of Part A services.
F ollow up on query escalations.
A ssist manager with CDI/UM education.
A ssist manager with all duties otherwise unspecified.
E ngage in a collaborative work environment with department manager.
P rovides feedback to attendings and consulting physicians regarding clinical status decisions and documentation.
C ommunicates with physicians regarding escalated CDI/UM issues.
C ommunicates with the Chief Medical Officer and the MSQI committee on issues that are not resolved at a Physician Advisor to physician level.
D evelops CDI/UM huddle educational content.
C ollaborates on CDI denials.
P rovide education for physicians and APP's at educational meetings.
U tilizes appropriate criteria to assist nurses with UM case review submission.
U tilizes appropriate language for CDI query formation.
U nderstands compliant query language.
A ssist DMG with medical necessity for Clinical Review Meetings with the payers.
P rovide metric and data information to manager and director on performance of CDI/UM.
D esign and coordinate with IT and the UM technician reports and research projects for advancement of CDI/UM.
A rrange, coordinate, and facilitate the Utilization Management Committee meeting each quarter including working with the UM technician to maintain binders and minutes.
R eview HFAP/ACHC standards and changes.
P rovide constructive feedback on queries, reviews, and performance in conjunction with the manager.
P articipate in continuing education through Racrelief google groups, covenant consulting initiatives and other PA professional societies.
R emain current on regulatory changes for CMS.
R eview and distribute the new Inpatient Only Procedure List.
R eview and update the Utilization Management Committee Plan and provide a redline copy to the executive team administrative assistant for approval at committees.
R eview and work collaboratively with the Manager on CDI/UM process/policies/improvements.
E stablish relationships with lead medical directors.
Pr ovide education to the incoming CMU residents regarding CDI/UM.
P articipate in national conferences and societies on UM/CDI.
Other information:
EDUCATION/EXPERIENCE REQUIREMENTS
G raduate of an accredited medical school required.
C urrent State of Michigan medical license required.
C ompletion of a specialty residency.
M inimum of 3 years of experience in a hospital-based practice setting.
B oard certification preferred.
K NOWLEDGE/SILLS/ABILITIES
D emonstrates the ability to develop relationships .
D emonstrated ability to build rapport with medical staff and hospital leadership.
A bility to task switch and prioritize assignments based on revenue deadlines.
A bility to complete tasks by payer deadlines.
A vailable to work every other weekend and receive phone calls on emergent issues.
A vailable to work half of all holidays and receive phone calls on emergent issues.
S trong computer skills including application and use of the internet, EPIC, Excel, Powerpoint and Word.
D emonstrated ability to deliver high quality, cost-effective, efficient patient care services.
U tilization Management experience.
H ave familiarity with current medical literature, healthcare reimbursement issues (i.e. medical necessity, levels of care, coding), MCG/Inter Qual screening criteria, Medicare/Medicaid compliance, and medical staff structure, policies and procedures.
W ORKING CONDITIONS/PHYSICAL REQUIREMENTS
A bility to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.
C onstant sitting, talking, or hearing.
F requent standing, walking, lifting, carrying, and use of hands to finger, handle and feel.
F requent lift 0-25 lbs.
F requent near, far, depth perception, color vision, and field of vision.
O ccasional push, pull, balance, climbing, stooping, crawling, kneeling, crouching, taste or smell.
O ccasional lift 26-50 lbs.
NOTICE REGARDING LATEX SENSITIVITY IN APPLICANTS FOR EMPLOYMENT.
I t has been determined that Covenant HealthCare cannot provide a latex safe or latex free work environment at any of its facilities. Unfortunately, that means that any individual, including an applicant or an employee, is likely to be exposed to latex while on Covenant's premises. Therefore, latex tolerance is considered to be an essential function for any position with Covenant.
Created: 2024-06-04
Reference: 19563
Country: United States
State: Michigan
City: Saginaw
ZIP: 48607
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