To be fully engaged in providing Quality/No Harm, Customer Experience, and Stewardship by\:
The Physician Advisory (PA) conducts clinical reviews on cases referred by care management staff and/or other health care professionals to meet regulatory requirements and in accordance with the hospitals objectives for assuring quality patient care and effective, efficient utilization of health care services. The PA meets with care management and health care team members to discuss selected cases and make recommendations for care, interacting with medical staff members and medical directors f third party payers to discuss the needs of patients and alternative levels of care. The PA acts as consultant to and resource for attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources. The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations.As the CDI physician advisor, the PA will act as a liaison between the CDI professional, HIM, and the hospital's medical staff to facilitate accurate and complete documentation for coding and abstracting of clinical data, capture of severity, acuity and risk of mortality, in addition to DRG assignment.
Reviews medical records of patients identified by care managers or as requested by the healthcare team in order to\:
Assist with level of care and length of stay management
Assist with the denial management process
Review and make suggestions related to resource and service management
Assist staff with the clinical review of patients
Determine if professionally recognized standards of quality care are met
Provides feedback to attending and consulting physicians regarding level of care, length of stay, and quality issues. Seeks additional clinical information from the attending and consulting physicians. Recommends and requests additional, more complete, medical record documentation. Recommends next steps in coordination of care and evidence-based medicine indicators.
Reviews cases that indicate a need for issuance of a hospital notice of non-coverage/Important Message from Medicare. Discusses the case with the attending physician and if additional clinical information is not available, discusses the process for issuance and appeal to the physician.
Documents patient care reviews, decisions, and other pertinent information. Understands and uses InterQual/MCG and other appropriate criteria. Documents response to case management referrals. Supports Care Management in a data-driven approach.
Notifies the care manager of any conflict of interest in reviewing a particular patient record. Assists with identifying a physician to review such record.
Acts as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate.
Facilitates, mentors, and educates other physicians regarding payer requirements.
Participates 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. Participates in patient rounds with the Healthcare Team as indicated.
Identifies patients who are appropriate for transfer to LTACH facilities and works with physicians to facilitate referrals as needed.
Provides guidance to ED physicians and ED Care Management regarding status issues and alternatives to acute care when acute care is not warranted.
Works with Care Management and an interdisciplinary team to ensure appropriate continuity of care and to reduce re-admissions.
Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, alternative levels of care, community resources, and end of life care. Works with physicians to facilitate referrals to the continuum of care.
Assists physicians with end of life and hospice care consultations when appropriate.
Provides education to physicians and other clinicians regarding inappropriate admissions to the ICU and creates action plans to address these patients.
Identifies quality, safety, patient satisfaction and efficiency issues leading to suboptimal care. Takes appropriate action to resolve.
Promotes and educates healthcare team on a team approach to patient care. Promotes coordination, communication and collaboration among all team members.
Supports the organization in quality improvement efforts requiring physician input and/or involvement.
Educates individual hospital staff physicians about ICD 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 regarding\:
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.
ways to provide improved health record documentation that specifically affect ICD code assignment
capture of severity, acuity, risk of mortality, and DRG assignment.
Graduate of an accredited medical school
Licensed in the State of Florida
Evidence of continuing medical education in utilization management
Experience in UR/care coordination efforts for high performing hospitals, regional operations and/or health systems
Prior physician advisor experience preferred
Ability to translate broad strategies into specific objectives and initiatives
Ability to conceptualize in unstructured, dynamic and multifaceted environments that require foresight, intuition and mature judgment
Ability to analyze complex systems and processes, synthesize relevant theories, principles and evidence and determine solutions challenging problems
Ability to communicate effectively through various medium and diverse audiences
Ability to facilitate teams and projects to accomplish objectives in a resourceful and timely manner
Internal Number: 229_033776
About Health First
Health First is Central Florida's only fully integrated health system. With a mission to positively change the health and wellness of the communities we serve, Health First offers the latest technological advances and quality care at our four hospitals and through our many Outpatient & Wellness Services, as well as the area's only Trauma and Heart Centers. Health First also offers multiple commercial and Medicare health plans, the largest multi-specialty physician group in Brevard County, and four fitness centers to help members of our community stay healthy.