As the Utilization Management Physician Advisor (PA), the PA conducts clinical case reviews referred by case management staff and/or other health care professionals to meet regulatory requirements and, in accordance with the hospital’s objectives for providing quality patient care, to assure effective and efficient utilization of health care services. The PA communicates remotely with case and utilization management to discuss selected cases and make recommendations regarding level of care, as well as, communicates remotely with medical staff members and medical directors of third-party payers to discuss the needs of patients and options/alternatives for care. The PA acts as a consultant to, and resource for, attending physicians regarding their decisions relative to appropriateness of hospitalization, appropriate level of care for initial hospitalization and continued stay days, clinical documentation, and use of healthcare resources. The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations. The PA must demonstrate interpersonal and communication skills and must be clear, concise and consistent in the message to all constituents.

Key Responsibilities:

• Contacts Case and Utilization Management Teams: Makes telephonic/electronic contacts with case and utilization management to discuss clinical aspects of hospital encounters, as well as, medical necessity and appropriate levels of care.
• Conducts medical record review in appropriate cases for medical necessity of hospital admission, continued hospital stays, adequacy of discharge planning and quality care management.
• Conducts Peer to Peer discussions with payers as needed.
• Understand the intricacies of ICD-9-CM, ICD-10-CM/PCS, MS-DRG, and APR-DRG.
• Understand the intricacies of the Medicare Inpatient Prospective Payment System (IPPS) to make medical determinations on severity of illness, acuity, risk of mortality, and communicate with treating physicians in cooperation with the utilization team and health information staff.
• Contacts Attending Physicians: Makes telephonic/electronic contacts with Attending Physicians to discuss clinical aspects of hospital encounters, as well as, medical necessity and appropriate levels of care. Discussion may also include education for improved clinical documentation, in addition to, governmental and commercial guidelines for reimbursement.

• Experience performing Peer to Peer Reviews, preferred
• Minimum of 5 years of clinical practice required.
• Broad knowledge base with trust and respect of medical staff physicians.
• Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills.
• Minimum of 1 year of experience as a Physician Advisor required.
• Education in quality and utilization management through continuing medical education programs and self-study.
• Utilization management experience.
• MD or DO required
• In-depth knowledge of CMS regulations, including understanding of the 2-midnight rule.
• Unrestricted license in field of practice in one or more states required.
• Broad-based knowledge regarding clinical practice.