American College of Physician Advisors
JOB DESCRIPTION FOR PHYSICIAN ADVISORS
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In response to numerous requests for a Physician Advisor Job Description, it is important to acknowledge several key points to consider when creating a job description for a role as a Physician Advisor:
- There is no one job description that fits all models for the role of a Physician Advisor.
- All job descriptions for Physician Advisors will be individually unique to the particular situation within each organization. The Physician Advisor's job description should be tailored to the specific needs of the organization, or the specific role of the Physician Advisor within that organization.
- The term "Physician Advisor" is a generic and all-encompassing term to include the many diverse functions that potentially fall within the scope of the Physician Advisor role.
- All or part of the Physician Advisor's job description template may also help delineate the various roles performed by a Physician Advisor, but under different titles such as: Medical Director of Care Management, Director of Utilization Management, Medical Director of Denial and Appeals, Chief Medical Compliance and Regulatory Officer, Physician Champion for Care Management and CDI, etc.
- Most job descriptions for the Physician Advisor's role broadly outline the scope of responsibilities and expectations for the various categories of that particular job function.
In general, the American College of Physician Advisors, Inc. recommends defining the organizational expectations and job responsibilities within a Physician Advisors job description to include the reporting responsibilities, outlining the categorical expectations, and listing the measurable performance expectations. The following job description example should serve only as an outline or template for consideration and is not intended to be all inclusive, inflexible or uniform across the profession.The format as presented allows you or your organization to select individual statements or categories for the easy application to your specific organizational needs.
The ACPA is pleased to offer this benefit to all ACPA physician members and associate members as part of our organizational commitment to provide our membership with the best information and resources available for the advancement of the Physician Advisor profession.
Job Title: Physician Advisor
(Aka: Medical Director for Care, Management, Chief Physician Advisor, Medical Director of Utilization Management, Chief Physician Compliance and Medical Appeals Officer, Physician Advisor Coding Documentation and Integrity Specialist, Chief Medical Compliance and Regulatory Officer, etc.)
The Physician Advisor is a key member of the healthcare organization’s leadership team and is charged with meeting the organization’s goals and objectives for assuring the effective, efficient utilization of health care services. The Physician Advisor is a physician serving the hospital through teaching, consulting, and advising the care management and utilization review departments and the hospital leadership. The Physician Advisor shall develop expertise on matters regarding physician practice patterns, over and under-utilization of resources, medical necessity, levels of care, care progression, denial management, compliance with governmental and private payer regulations, appropriate physician coding and documentation requirements.
PRIMARY SCOPE OF SERVICE
The Physician Advisor works closely with the medical staff leadership, the entire medical staff, including resident physician house staff, all areas of resource management, case management, social services, discharge planning, 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, insuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities.
Reports directly to:
Chief Physician Advisor, Chief Medical Officer, VPMA, CEO Chief Quality, Safety Officer, etc.
MINIMUM JOB SPECIFICATIONS:
- Hold and maintain an unrestricted medical license in the state of (location).
- Meet the requirements (and become a member) of the Hospital medical staff
- Possess or acquire a solid foundation, knowledge, and/or experience in the areas of utilization management, quality improvement, and patient safety.
- Possess a working knowledge of (Hospital) organization & case management operations and administrative standards and policies.
- Strong computer skills and working knowledge of the Electronic Medical Record.
- Familiarity with MCG/Interqual placement status criteria is preferred.
- Member of the American College of Physician Advisors (ACPA) preferred.
- Board Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) preferred.
- Physician Advisor Sub-specialty Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) preferred.
- Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes
- Demonstrates behavior that supports the organization’s mission. Participates in required orientation and training related to the Physician Advisor role.
- Meets production standards within established time requirements. Work product and performance meets quality standards.
- Demonstrates respect and uses positive interpersonal skills with patients, clients, the public, managers, and employees at all times.
- Maintains confidentiality of patient care and business matters.
- 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.
- Obtains familiarity and working knowledge of standard published criteria such as MCG/InterQual and applies professional judgment and patient specific variables as may be necessary or justifiable.
- Demonstrates commitment to meeting/exceeding strategic initiatives of organization.
- Maintains accountability for achieving case management outcomes and fulfills the obligations and responsibilities of the role to support the medical staff in the clinical progression of patient care.
- Reviews issues identified by case managers to ensure appropriate follow-up, recommend improvement initiatives as needed, and make referrals to the appropriate department chair as necessary.
- Responds to requests for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management department in a timely fashion.
- Upholds the organization’s values of team work and professionalism and applies Code of Conduct standards to all members of the healthcare team.
- Provides consultation to nurses and case management staff regarding complex clinical issues and advises on justification required for continued stay, medical necessity and utilization management.
ESSENTIAL JOB DUTIES AND ACCOUNTABILITIES
OTHER SKILLS OR SPECIAL ABILITIES:
- Excellent customer service and interpersonal skills.
- Able to effectively present information, both formal and informal.
- Strong analytical skills.
- Strong written and verbal communications skills with all levels of internal and external customers.
- Strong organizational skills and ability to set priorities and multi-task, demonstrates flexibility, teamwork, and is accustomed to change in the healthcare environment.
- Demonstrates ability to drive results and produce outcomes.
ACUTE INPATIENT/CASE MANAGEMENT FUNCTIONS:
- Review medical records of patients identified by case managers or as requested by the healthcare team in order to perform quality and utilization oversight
- Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews
- Assist with length of stay management and utilization of resources
- Assist with the denial management process
- Review and make suggestions related to resource and service management
- Perform reviews for determining professionally recognized standards of quality care
- Provide regular feedback to physicians and all other stake holders regarding level of care, length of stay, and potential quality issues
- Recommend and request additional and more complete medical record documentation to support placement status or medical necessity
- Review cases that indicate a need for issuance of a hospital notice of non-coverage/Important Message from Medicare (HINN). Discuss the case with the attending physician and if additional clinical information is not available, coordinate the process with the Care Manager for issuance of HINNs
- Understand and use MCG/InterQual and other appropriate criteria. Document response to case management referrals. Support Case Management in a data-driven approach
- Facilitate pre-payment reviews and/or participating in recovery audit contractor reviews
- Assist Hospital Administration in billing for the technical component of the services rendered by the Departments, including initial billings, follow-up reports, and appeals in cases of retrospective denials
- Assist Hospital Administration and the Medical Staff in connection with any regulatory audits, investigation, survey, or other review of the Departments
- Ensure consistency of utilization review services, quality control, and patient safety
- Act as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate by participating in Peer to Peer discussions and reviews
- Facilitate, mentor, and educate other physicians regarding payer requirements
- Participate in review of long stay patients, in conjunction with the Care Management Leadership, Care Management team, and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care
- Participate in Interdisciplinary Rounds (IDT) with the Healthcare Team as indicated
- Provide guidance to ED physicians and ED Case Management regarding status issues and alternatives to acute care when acute care is not warranted
- Work with Care Management and an interdisciplinary team to insure appropriate continuity of care
- Participate in all organizational efforts to reduce inappropriate readmissions
PHYSICIAN SUPPORT, EDUCATION, AND COLLABORATION:
- Provide education to physicians and other clinicians related to regulatory requirements, appropriate utilization of hospital services, community resources, and alternative level of care.
- Provide education to physicians and other clinicians regarding inappropriate admissions and create action plans to address this issue.
- Provide physician coaching and on-going education on appropriate clinical documentation improvement and care standards as may be appropriate.
- Conducts physician education sessions to share data, trends, practice patterns, and other relevant information as requested.
- Ensures physician accountability for efficient patient care management.
- Investigates avoidable delay concerns referred by case management staff that effect patients' outcomes during their hospital stay.
- Contacts physicians in a timely manner to resolve delays and achieve positive outcomes.
- Demonstrates positive outcomes through interventions with attending or consulting physicians that delay care and affect the length of stay or avoidable delays, etc.
- Identifies denial trends and works with the medical staff and hospital administration to resolve the issue.
- Reports practice pattern trends and opportunities to service line or department specific meetings at the request of the CMO, Vice President of Care Management, or hospital leadership.
ORGANIZATIONAL PROCESS IMPROVEMENT:
- Identify quality, safety, patient satisfaction, and efficiency issues leading to sub-optimal care. Take appropriate action to resolve.
- Promote and educate healthcare team on a team approach to patient care. Promotes coordination, communication, and collaboration among all team members.
- Support the organization in quality improvement efforts requiring physician input and/or involvement.
CLINICAL DOCUMENTATION IMPROVEMENT SUPPORT:
- Educates individual hospital staff physicians about ICD-9 and 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.
- Educates specific medical staff departments (e.g., Internal Medicine, Surgery, Family Practice, etc.) at departmental meetings on coding and documentation improvement guidelines.
- Explains reasons why individual physicians should be concerned about correct disease reporting and the subsequent ICD code capture of severity, acuity, risk of mortality, and DRG assignment, such as: Physician performance profiling, physician E&M payment and pay for performance, appropriate hospital reimbursement and profiling for patient care.
- Describes ways to provide improved health record documentation that specifically affect ICD code assignment capture of severity, acuity, risk of mortality, and DRG assignment.
- Develop structure and implement a clinical documentation improvement and integrity program, taking into account the makeup of your medical staff, medical process environment of the hospital, medical coder competency/skill sets, and overall strategic planning of the organization.
- Build strategies for Medicare important message compliance in collaboration with care management.
- Develop the skills for screening for medical necessity, ensuring the appropriate level of care and properly crafting clinical queries using established guidelines. Discuss how to recognize when a clinical query is needed with members of the CDI team.
- Provide strategies to minimize risk and reduce provider liability or loss of inpatient revenue.
- Build and expand upon time-tested proven strategies that contributed to the development and implementation successes of clinical documentation improvement.
- List pitfalls to avoid in the development and implementation phases of your program that will jeopardize the probability of success in and buy-in from the medical staff.
- Effectively communicate physician teaching points for immediate and future clinical case studies.
- Develop succinct discussion points for physicians to utilize upon the opportunity to present teaching points that stress the application of medical records documentation beyond claims data into administrative data.Explain the role of administrative data in today's business of medicine - and the future of medicine.
MEDICAL INFORMATICS SUPPORT:
- Works with the IT Leadership team to ensure the system appropriately supports the physician's ability to provide best practice medicine by creating logical processes and providing the necessary order sets and practice guidelines.
- Participates in physician education and outreach efforts.
- Works in collaboration with the IT team to be sure all necessary physicians are trained and training is appropriate for the physicians.
- Participates as part of the physician advisory council to assist with clinical decisions for the Electronic Health Record (EHR).
- Assists with order set development, review, and implementation to coordinate quality, efficiency, and utilization of the order sets, as requested.
ADDITIONAL EXPECTATIONS AND RESPONSIBILITIES
- Attend all meetings as requested by Hospital administration and include participation in assigned Hospital committees, meetings, and other activities, such as hospital quality and performance committees, medical audit and utilization review committees.
- Upon request, actively participate in Hospital committees to develop protocols related to evidence based medicine and support optimal standards of care.
- Participate in the educational programs conducted by the Hospital to the extent necessary to ensure the Hospital’s overall compliance with accrediting and regulatory requirements.
- Ensure the timely, accurate, and adequate completion of all medical records, including sufficient documentation of medical necessity and correct coding for the services rendered, in compliance with the Medical Staff Bylaws.
- Participate in risk management and quality assessment and improvement activities.
- Attend (Hospital) sponsored education programs designed to promote adherence to laws, regulations, policies, and procedures relevant to Physician Advisor.
- Conduct presentations to Medical Staff, Hospital Board/Administration as warranted as may be related to Physician Advisor areas of expertise or knowledge.
- Chairs or serves on the Utilization Management Committee (UMC).
- Participate in the peer review process as may be necessary or requested.
- Assist with the evaluation of the hospital utilization management program, including adherence to the required CMS Conditions of Participation.
- Maintain current knowledge of federal, state, and payer regulatory and contract requirements.
- Attend continuing education sessions pertaining to utilization and quality management.
OUTCOMES AND DELIVERABLES:
- Submits monthly record of performance metrics or data as requested to the CMO (or direct report).
- Maintains documentation of the number of interventions and resulting outcomes or decisions.
- Documents education sessions for medical staff on trends, practice patterns, or relevant information.
- Tracts and reports appeal and denial results where Physician Advisor intervention was required.
This job description is designed to describe the general nature and level of work performed by employees within this classification. It is not designed or to be interpreted as a comprehensive inventory of all duties and responsibilities required of employees assigned to this job.
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