Job Description :
This job assures the most cost-effective, appropriate use of health care services for patients treated at Allegheny Health Network while correlating patient clinical information with insurance information (criteria) regarding severity of illness, intensity of service and the appropriateness of the setting for the administration of that care. He/She communicates with and provides clinical information to third party administrator physicians for the purpose of securing payment authorization. Collaborates with physicians and other hospital personnel, including Case Management and the Clinical Resource Management Committee, in order to integrate and manage this care. This position reports into the hospital Chief Medical Officer with a matrix report to the Director of Physician Advisors.
- Physician Advisor - AHN
- Works in concert with the admitting physician, Case Management, and other hospital personnel, to evaluate the medical necessity and appropriateness of: admission to the hospital, utilization of observation status and services for those patients, continued stay in the hospital and ancillary services ordered. When appropriate, discuss case with attending physician regarding medical necessity.
- When requested, discuss case with insurance company physician administrator for the purpose of obtaining payer authorization.
- Provide medical expertise, advice and support to the Case Management Department.
- Provide education to the medical staff regarding medical necessity and appropriateness of health care services.
- Provides ongoing education to colleagues regarding observation status and case management.
- Assist with appeals of denials and participates in data collection activities for resource utilization management.
- Receives daily report form Nursing Service (Bed Management) and Case Management on all observation cases.
- Reviews the status of observation cases, facilitates use of institutional processes and communicates with attending physicians and case managers regarding the status of the patient.
- Assists with admission, treatment and discharge orders in coordination with the attending physician.
- Conducts interdisciplinary rounds to drive quality and reduce length of stay.
- Interacts regularly with coding and clinical documentation specialists.
- The Physician Advisor would be an active member of the Clinical Resource Management Committee.
- Participates in Payer contract reviews to determine criteria set forth to avoid unnecessary denials.
- Reports data on case management and observation services to the Committee.
- Doctorate in Medicine, MD or DO
- 5 years clinical practice experience in a hospital setting required
- Physician Advisor experience in clinical setting
- Physician Advisor experience with cross-functional teams
- Physician Advisor experience with large health system
- Physician Advisor experience with integrated payer / provider network
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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