Physician Advisor - Winchester, MA
The Physician Advisor is responsible for managing the efficiency of care delivered at the organization and is accountable to the Medical Director of Utilization Management and Case Management. The Physician Advisor works with the medical and nursing staff leadership and the hospital, and closely collaborates with the director of case management and social work. The Physician Advisor ensures proper discharge planning and utilization management by developing and implementing methods to optimize use of hospital services for all patients while also ensuring the quality of care provided. This includes working with those developing case management protocols, working with physicians and others to reduce length of hospital stay, ensuring patients are in the appropriate level of care, and monitoring the appropriate use of diagnostic and therapeutic modalities.
The Physician Advisor is responsible for assisting the organization to challenge physician practices in order to achieve the organization’s desired resource management and quality goals.
Essential duties and responsibilities include but are not limited to:
Clinical Effectiveness:
• Demonstrate commitment to meeting/exceeding strategic initiatives of organization.
• Maintain accountability for achieving case management outcomes and fulfilling the obligations and responsibilities of the role to support the medical staff in the clinical progression of patient care.
• Review 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.
• Respond to requests for assistance within 30 minutes during normal duty hours.
• Uphold the organization’s values of team work, interacting with others with dignity and respect.
• Provide consultation to nurses and case management staff regarding complex clinical issues and advises on next steps.
Revenue Cycle:
• Work collaboratively with the hospital leadership to ensure maximize performance on all the hospital based performance measures.
• Appeal and denial process – Evaluation of processes, source of denials and reason to respond to payers this includes peer to peer discussion and preparation of substantiating information to support the submit charges.
• Review of denial causation implementation of corrective actions and tracking of effects.
• Medicare RAC Review – physician lead on the RAC process
• Clinical Documentation Improvement – evaluate gaps and opportunities and educate the physician and other staff on proper documentation to ensure proper reimbursement for services rendered
• Clinical consultation to finance, billing and coding on issues pertaining to clinical documentation, level of services etc.
• Reductions in length of stay and unnecessary admissions.
Collaboration:
• Facilitate internal and external relationships with all physician and constituents of case management.
• Create strategies to enhance hospital and post-acute interdisciplinary efforts for maximizing patient/family outcomes. Serve as an advocate for the case management service.
• Participate in developing and maintaining positive relationships with third-party payers. Ensure processes are followed according to policy and contracts.
• Interact with the medical staff to achieve optimal outcomes on case specific issues.
• Collaborate with clinical care services and the medical staff
• Demonstrate excellent customer service and interpersonal skills.
Utilization Management:
• Communicate with the payer’s medical directors and physician advisors as requested to resolve any disputes surrounding medical necessity approvals for continued stay.
• Participate in level of care determinations on a case-by-case basis as requested by case managers.
• Collaborate with all department personnel as requested.
• Authorize all appeal letters via signature.
• Co-chair the Utilization Review Committee with the case management director.
Physician Liaison:
• Conduct physician education sessions to share data, trends, practice patterns, and other relevant information as requested.
• Ensure physician accountability for efficient patient care management.
• Participate in coaching and educating physicians on the appropriateness of level of care and timely need for discharge planning.
• Investigate avoidable delays concerns referred by case management staff that effect patients’ outcomes during their hospital stay.
• Contact physicians to resolve delays and achieve positive outcomes.
• Demonstrate positive outcomes through interventions with attending or consulting physicians that delay care and affect the length of stay or avoidable delays, etc.
• Identify denial trends and work with the medical staff and hospital administration to resolve the issues.
• Reports practice pattern trends to the medical director, care management and the director of case management.
• Perform other responsibilities as requested
Outcomes and Deliverables:
• Submit monthly record of performance to the Medical Director of Utilization Management and Case Management which includes:
- Number of interventions and resulting outcomes
- Reduction in number of cases on weekly outlier list (15 days or more LOS)
- Quarterly education sessions for medical staff on trends, practice patterns, or relevant information
- Quarterly written articles in organizational newsletter on timely case management and resource management issues
- Maintain clinical case denial rate below 2%.
Organizational Requirements:
• Maintain strict adherence to the Lahey Health Confidentiality policy.
• Incorporate Lahey Health Standards of Behavior and Guiding Principles into daily activities
• Comply with all Lahey Health Policies.
• Comply with behavioral expectations of the department and Lahey Health.
• Maintain courteous and effective interactions with colleagues and patients.
• Demonstrate an understanding of the job description, performance expectations, and competency assessment.
• Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.
• Participate in departmental and/or interdepartmental quality improvement activities.
• Participate in and successfully completes Mandatory Education.
• Perform all other duties as needed or directed to meet the needs of the department.
• Participates in required orientation and training related to the Physician Advisor role.
• Meet production standards within established time requirements. Work product and performance meets quality standards.
Minimum Qualifications:
Education: Doctor of Medicine or Osteopathy. Completion of specialty residency and board certification in internal medicine, emergency medicine or family medicine.
Licensure, Certification & Registration: License to practice medicine as a physician in the Commonwealth of Massachusetts.
Experience: Preferred Minimum three years’ experience in managed care, quality management, utilization review, resource management, at the payer or provider (hospital) level.
Skills, Knowledge & Abilities: Advanced interpersonal skills coupled with excellent presentation and communication skills essential for effectively managing sensitive matters with tact and representing Northeast Hospitals internally and externally. Advanced analytical skills necessary to integrate and interpret data from diverse sources in order to determine optimal course of action. Advanced knowledge of the health care delivery system including regulations, trends, policies and procedures related to quality and safety. Ability to build consensus and lead toward common objectives. Familiarity with metrics used by Lahey to measure quality and patient satisfaction. Ability to build rapport with medical staff and management leadership to obtain necessary approvals of new strategies for utilization management. Dedication to the delivery of high-quality, cost-effective, efficient patient care services. Maintenance of clinical competency by active clinical practice within specialty.
Key Relationships:
• Medical Director of Utilization Management, Chief Medical Officers, Associate Chief Medical Officers, Division and Department Chairs Program design, implementation and collaboration to achieve program goals.
• Medical Staff Leadership, Medical Staff Program implementation and collaboration to achieve program goals
• Resource management, Case Management/Social Work, Discharge Planning, Utilization management, HIM, Compliance Program administration; including communication, training and development of policies and practices.
• Patients and Families.
• Appropriate attention to patient safety and patient care
Winchester is a highly desirable suburban Boston community. Winchester offers a variety of housing options, excellent schools, and an array of social, cultural and recreational amenities, as well as easy access to downtown Boston. It is truly a very desirable area in which to practice and live
Interested candidates are encouraged to send CVs and letters of introduction to:
David DeLuca
Senior Physician Recruiter
Lahey Health
Burlington, MA 01805
Phone: 781-744-8646
David.deluca@lahey