Medical Director Revenue Integrity (Physician Advisor)

PRIMARY SCOPE OF SERVICE:

The Physician Advisor collaborates closely with the medical staff leadership, the entire medical staff, all areas of resource management, case management, and utilization management 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 length of hospital stay and efficient management of resources, ensuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities.

GENERAL REQUIREMENTS:

MINIMUM JOB SPECIFICATIONS:

• Hold and maintain or able to obtain an unrestricted medical license in the state of Wyoming.
• Possess or acquires a solid foundation, knowledge, and/or experience in the areas of utilization management, quality improvement, and patient safety.
• Familiarity with InterQual and MCG is preferred.
• Strong understanding of Medicare Two Midnight Rules
• Member of the American College of Physician Advisors (ACPA) .
• Board Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) or ACPA is required within 6 months of hire
• Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes.
• Prefer Internal Medicine specialist with a background in Hospital Medicine.
• Maintain active medical practice in their specialty (Can accommodate clinical time up to 0.15 FTE in the specialty (depending on availability).

ORGANIZATION EXPECTATIONS:

• Demonstrates behavior that supports the organization's mission.
• Adheres to all professional and performance expectations set forth within the medical staff bylaws, rules & regulations and complies with all (Hospital) established policies and procedures.
• Participate in ongoing training and education related to the Physician Advisor role and responsibilities including topics related to Utilization Management, Care Management and other related areas as requested.

ESSENTIAL JOB DUTIES AND ACCOUNTABILITIES

LEADERSHIP:

• Provide functional leadership for the revenue integrity team Including CDI, Coding and Utilization Review.
• Responsible for oversight revenue integrity optimization.
• Lead value-based care initiatives for the organization.
• Chairs the Utilization Management Team.

UTILIZATION REVIEW SUPPORT:

• Review medical records of patients identified by case managers or as requested by the healthcare team including physicians to perform quality and utilization oversight.
• Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews.
• Conduct Peer to Peer discussion with Payor Medical Directors when requested.
• Provide regular feedback to physicians and all other stake holders regarding level of care, length of stay, and potential quality issues.
• Provide necessary clinical education to UR Case Managers regarding clinical criteria and appropriate use of screening tools.

CLINICAL DOCUMENTATION INGERITY and QUALITY REPORTING SUPPORT:

• For Medical Staff
  • Educates individual hospital staff physicians about ICD-10 and DRG coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records.
• For CDI and Coding Team
  • Collaborate to develop complaint query practices.
  • Collaborate to optimize CDI and Coding review process.
  • Provide necessary clinical support when requested by the team in DRG assignment.

DENIAL MANAGEMENT AND PREVENTION:

• Prefer or willing to learn outpatient denials management
• Provide clinical support to CDI Manager and RAC auditor for DRG and Level of care denails
• Provide necessary education and feedback to providers regarding denials and improve documentation strategies to prevent denials.

PHYSICIAN LIAISON:

• Conducts physician education sessions to share data, trends, practice patterns, and other relevant information as requested.
• Proactively reports practice pattern trends and opportunities to service line or department specific meetings at the request of the CMO or hospital leadership.
• Proactive approach to optimize the service line revenues (professional billing)

ORGANIZATIONAL PROCESS AND QUALITY IMPROVEMENT:

• Collaborate with Healthcare Data Team in identifying areas or process contributing to excessive cost of care.
• Upon request, actively participate in Hospital committees to support to develop protocols related to evidence-based medicine and support optimal standards of care.
• Support Payor Contract Process
• Support physician contract process for quality measures.

OUTCOMES AND DELIVERABLES:

• Documents education sessions for medical staff on trends, practice patterns, or relevant information.
• Develop KPI (dashboard) to monitor progress of revenue integrity
• Collaborate with CFO to identify short term and long-term goals.
• Establish Quality Measures for every 6 months in collaboration with CFO.

Equal Opportunity Employer
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