Facility: WCO - Wellstar Corporate Office

Job Summary:

The Executive Director, MD Physician Advisor reports to and is accountable to the Lead Executive Director of Physician Advisor, who reports to the Vice President Medical Outcomes. This role has similar duties to the Executive Director of Physician Advisor, as well as Denials Medical Director to impact utilization management and retrospective denials, but will not have any expanded quality improvement roles.
Utilization Management: The PRN Physician Advisor (PA) will conduct clinical review cases sent for review for commercial payers, governmental, and medicare advantage plans that are referred by Care Coordination/Case Management staff and/or other health care professionals to assess for appropriateness of care; proper level of care in accordance with hospital objectives for assuring quality patient care and effective, efficient utilization of health care services, and to meet regulatory requirements. Working as a peer to physicians and as a consultant to Care Management and administration, the PA intervenes when practice patterns or behaviors or documentation issues create disparity between pathway standards, intensity of service, severity of illness, patient and family rights, teamwork, or other issues regarding the stewardship of resources for individual patients, diagnostic populations, and the organization as a whole.

Core Responsibilities and Essential Functions:

The PRN Physician Advisor (PA) will work closely with Utilization management team to provide timely consultation and clinical expertise to ensure fiscally responsible and efficient utilization of resources. These duties will include but not be limited to areas such as concurrent assessment of the clinical situation, determination of medical necessity and appropriate level of care, real time feedback to physicians and case managers and all necessary follow-up with appropriate and clear communications of next actions to physicians; care coordinators, social workers, nursing staff and other key people involved in caring for individual patients whose cases have been referred for consultation:
a) Assist with level of care and length of stay management. This will include assessment of Inpatient vs. Outpatient Obs. Status; Compliance with 2 MN Rule, assistance with throughput initiatives and care transition issues.
b) Assist with denial management process on a concurrent basis or retrospective basis.
c) Work closely with the Utilization Management to expedite case management issues and manage work queues.
d) Review and make suggestions regarding resource and service management.
e) Assist staff with clinical review of patients.
f) Review clinical records for appropriate and accurate clinical documentation to ensure that medical necessity and level of care for services will be substantiated.
g) Will work with the Clinical Documentation Excellence Specialists (i.e., CDS/CDI) to assist with physician queries for documentation or clinical criterion clarification.
h) May be involved in development and planning of care for specialized patient populations or those requiring Complex Disease & Care management.
i) Plan and develop any programs necessary to help facilitate the management of patient populations through the continuum of care.
j) Determine if professionally recognized standards of quality care are met by working with the Quality Department and available resources with appropriate referral to the Peer Review process if necessary.
k) Assist in review of any reports from regulatory agencies, i.e., RAC audits, QIO reports, etc. to help determine trends, develop replies to inquiries and action plans for improvement.
l) As part of his/her duties, the Physician Advisor will participate off-hour schedule to support the UM team on weekends and holidays. The PRN PA will be tasked to cover any Wellstar facility during normal business hours for vacations, unexpected absences or if case volumes at one or more facilities require additional help in managing the workload.
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• Doctorate Medicine or Doctorate Osteopathic Medicine

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• Doctor of Osteopathic Medicine or Medical Doctor

Additional License(s) and Certification(s):

Active MD/DO license with the State of Georgia with no restrictions. Required educational materials and training shall be completed as assigned by the supervisor. Upon Hire Required

Required Minimum Experience:

Minimum 3 years of clinical experience Required and
Some exposure to Utilization Management with a focus on clinical documentation, medical necessity assessment, billing and utilization review committee or similar. Required

Required Minimum Skills:

The PRN Physician Advisor must be able to communicate and understand verbal and written English language and display a positive attitude (see WellStars Credo).
Organizational skills that enable the individual to react and perform under stress and emergency situations and to manage two to three activities at one time on an ongoing basis.
Must display the character and disposition to foster physician engagement.
Time management skills to meet operational deadlines.