Physician Advisor (part Time)

Description

Position Summary Details

Physician Advisors provide concurrent review and appeal support services for XSOLIS's XPAS client base. Physician Advisors should possess professional expertise and the desire to be a part of an organization with proven experience to innovate, execute and deliver. Experience with utilization management and understanding of state and federal regulations, knowledge about the denials and appeals process, and experience with physician documentation and electronic health records is key. Physician Advisors apply practical working knowledge as a Physician Advisor to a solution that will change the way hospitals solve their administrative challenges.

Requirements

Essential Duties & Responsibilities

The essential functions include, but are not limited to the following:

• Provide clinical reviews in accordance with Managed Care and CMS Regulatory Requirements to:
  • Assist with level of care and length of stay management on a case-by-case basis
  • Assist with the denial management process
  • Determine if professionally recognized standards of quality care are met
  • Participate in the concurrent and retrospective appeal peer-review process"

• Provide feedback to internal and external partners regarding level of care, length of stay and quality issues, which may also include joining client meetings to review observations and trends in physician behavior and/or documentation. Recommend and request additional, more complete, medical record documentation. Provide guidance to internal and external staff regarding status issues and alternatives to acute level of care when such care is not warranted. Provide education to internal and external staff related to regulatory requirements, appropriate utilization, and alternative levels of care.
• Ensure appropriate documentation of patient care reviews, decisions, and other pertinent information. Be able to review cases with screening criteria, such as InterQual, MCG or other appropriate platforms. Develop and apply protocols related to evidence-based medicine and criteria.
• Work with internal and external Care Management staffs to ensure appropriate continuity of care and provide education to assist in reducing readmissions.
• Educate internal and external staff about ICD 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.
• Provide insight into the development of the XSOLIS appeal operations and technology platform. Work with the Data Analytics team and assist in the enhancement of clinical analytics.
• Maintain current knowledge of federal, state, and payer regulatory and contract requirements.
• Additional functions as deemed appropriate and warranted.
• Full-time physician advisors are required to complete peer to peer reviews

Minimum Qualifications (Knowledge, Skills, and Abilities)

Education:

• Graduate of an accredited medical school
• Additional education in quality and utilization management through continuing medical education programs and self-study

Experience:

• 5 years recent experience in clinical practice

Other:

• Utilization management experience as a member of the UM oversight committee or past physician advisor experience preferred
• Licensed physician without restrictions
• Knowledge of federal, state, and payer regulatory and contract requirements
• Verbal and written communication skills
• Basic computer skills, including typing, navigating browsers, etc.
• MS Office Suite
• Professional demeanor and interpersonal skills

Supervisory Responsibilities

This role does not have any direct reports and is a single contributor role.

Working Environment and Travel Requirements

• Work is typically in a normal office administrative environment involving minimal exposure to physical risks.
• Position requires little to moderate physical activity. Mostly sedentary work exerting up to 10 pounds of force occasionally or a negligible amount of force to lift, carry, push, pull, or otherwise move objects. Work involves sitting most of the time, but may involve walking or standing for brief periods of time. No significant stooping is usually required.
• This role requires travel to our home offices in TN for training.

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position.

Reasonable accommodations may be made to enable individuals with disabilities to perform the functions.