Company :
Allegheny Health NetworkJob Description :
The Allegheny Health Network (AHN) is recruiting a full-time Physician Advisor to join our team located in Pittsburgh, PA.
General Overview:
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 both government and commercial payer utilized regulations and criteria regarding severity of illness, intensity of service, and the appropriateness of the setting for the administration of that care. The Physician Advisor is responsible for level of care reviews and peer-to-peer discussions with payers if denials do arise. The role requires significant collaboration with the hospital’s interdisciplinary care team including Physicians, Case Managers, UM nurses, and the hospital leadership team. The Physician Advisor is an integral part of the Utilization Management Committee and participates in hospital and enterprise-level quality and throughput initiatives. This position reports to the Senior Vice President of Care Continuum and Transitions and the Medical Director of Physician Advisors.
Essential Responsibilities:
The Physician Advisor 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 the case with the attending physician regarding medical necessity.
When requested, discuss the case with the insurance company medical director to obtain payer authorization or conduct a peer-to-peer discussion in cases of a denial.
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 residents/colleagues regarding observation status and case management.
Assists with appeal letters and participates in data collection activities for utilization management.
Receives daily report from 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 patient's status.
Conducts interdisciplinary rounds to drive quality and reduce length of stay in concert with case management, physicians, and the rest of the multidisciplinary team.
Interacts regularly with coding and clinical documentation specialists.
The Physician Advisor is required to be an active member of the Utilization Management Committee.
Leads and reports data on case management and observation services on the bi-weekly Throughput Meeting.
The Physician Advisor needs to be able to review and analyze metric reporting dashboards and implement action plans if not meeting goals.
Qualifications:
Minimum:
5 years of clinical practice experience in a hospital setting required
Board Certified in any Medical Subspecialty
PhD/MD Graduate of an accredited medical school with a Doctor of Medicine (MD) or Doctor of Osteopathy (DO) degree
Current PA MD licensure in good standing; current unrestricted DEA certificate
Preferred:
Board Certified in Quality/Physician Advising
Physician Advisor experience in a clinical setting
Physician Advisor experience with cross-functional teams
Physician Advisor experience with large health system
Physician Advisor experience with integrated payer/provider network
AHN Proudly Offers:
Competitive Compensation Package
Health, Dental & Vision Insurance
Retirement Benefits
Generous PTO Plan
CME time and stipend
Additional benefits include, but not limited to: EAP, Employee Discounts, and Gym Discounts
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 any category protected by applicable federal, state, or local law.
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