Physician Advisor Director

Under the co-direction of the Executive Director of Reimbursement, Chief Medical Information Officer, and Associate Chief Medical Officer, the Physician Advisor Director provides leadership to a team of associate Physician Advisors that supports case management, social work, coding team, utilization review, population health, and other clinical members to provide cost efficient, high quality inpatient and observation care at GBMC Hospital. This management includes level of care reviews, all denial reviews and appeals management for all hospital patients. The Physician Advisor Director is responsible for clinical direction of these services and shall be responsible for the development, implementation and oversight of policies and procedures as they apply to the provision of assigned services.
The Physician Advisor Director is a 0.75 to 1.0 FTE and will report directly to the Associate Chief Medical Officer.

Education:

• Graduate of an accredited medical program. Additional education in utilization and quality management through continuing medical education program and self-study

Licensures/Certifications:

• Licensed as a physician in the State of Maryland
• Board Certified by the American Board of Internal Medicine, or other certifying Board as deemed appropriate by Chief Executive Officer.

Experience:

• 2-4 years of recent experience and expertise in Utilization Management and Clinical Quality Management and 5 years of direct clinical experience.
• Has knowledge of Pay for Performance/VBP initiatives and incentives.

Skills:

• A high level of interpersonal skills to allow effective communications and interaction with a wide variety of hospital personnel, physicians, and the general public
• Documented interest and experience in the education and quality improvement needs for the various service lines under his/her responsibility
• Familiarity with Clinical Documentation requirements and working knowledge of Centers for Medicare and Medicaid services, rules and regulations.

Principal Duties and Responsibilities:

• Serves as physician expert and provides support to care team and Case Management, UR and Social Work staff regarding utilization decisions including screening for appropriateness of hospitalization, Level of Care (LOC), patient billing status management, Length of Stay LOS) management, continued stay decisions, clinical review of patients, utilization review activities, resource utilization/management, denial management issues, transitions of care/discharge planning (TOC/DP) advice, and quality of care issues
• Works productively with all department leaders to ensure that clinical care is consistent with current scientific advances and best evidence existing in published clinical literature or as established by recognized professional associations.
• Provides input at least annually for strategic and operational planning purposes and an assessment of Case Management, UR and DC/TOC efficiency and effectiveness.
• Makes recommendations to the Hospital’s administration regarding the use of hospital personnel, any necessary equipment, and general quality standards of patient care.
• Provides leadership and support to develop and maintain effective UM coverage at all points of entry to the Hospital (POE’s). POE process should be inclusive of UR appropriateness, admission avoidance, discharge planning and internal/external resource utilization.
• Supports effort to formalize PA, CM, and Revenue Cycle department operational integration (weekly or bi-weekly) to ensure claims are paid, and that medical necessity issues are addressed concurrently.
• Review denials for patients in the hospital or recently discharged and conduct peer-to-peer consultations with attending physicians as appropriate.
• Review requests for accommodation codes, reviews daily report for status change for Medicare patients and other requests for status and makes recommendations/decisions based on consultations with attending physician.
• Reviews all denials and is responsible for the administration of the appeals process, including completion of appeal letters, and communication & education of medical staff.
• Provide oversight of the development and approval of all operating policies and procedures for Physician Advisor services in conjunction with the responsible Administrator.
• Represents, or appoints designee to represent the hospital’s interests to external organizations concerned with denial management/Medicare or insurance providers.
• Collaborates with PA peers/mentors on an inter-rater reliability (IRR) process to capture standardized policies and procedures that can be used to support overall program strategy and utilization management approach.
• Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, and alternative levels of care
• Educates specific medical staff departments (Hospitalists, Surgery, Residents, etc.) at department meetings regarding correct disease reporting, ICD code assignment, capture of severity and overall hospital reimbursement policies.

All roles must demonstrate GBMC Values:

Respect

I will treat everyone with courtesy. I will foster a healing environment.

• Treats others with fairness, kindness, and respect for personal dignity and privacy

• Listens and responds appropriately to others’ needs, feelings, and capabilities

Excellence

I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others.

• Meets and/or exceeds customer expectations
• Actively pursues learning and self-development
• Pays attention to detail; follows through

Accountability

I will be professional in the way I act, look and speak. I will take ownership to solve problems.

• Sets a positive, professional example for others
• Takes ownership of problems and does what is needed to solve them
• Appropriately plans and utilizes required resources for various job duties
• Reports to work regularly and on time

Teamwork

I will be engaged and collaborative. I will keep people informed.

• Works cooperatively and collaboratively with others for the success of the team
• Addresses and resolves conflict in a positive way
• Seeks out the ideas of others to reach the best solutions
• Acknowledges and celebrates the contribution of others

Ethical Behavior

I will always act with honesty and integrity. I will protect the patient.

• Demonstrates honesty, integrity and good judgment
• Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers

Results

I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals.

• Embraces change and improvement in the work environment
• Continuously seeks to improve the quality of products/services
• Displays flexibility in dealing with new situations or obstacles
• Achieves results on time by focusing on priorities and manages time efficiently

Pay Range

$148,140.24 - $266,652.44Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.

Equal Employment Opportunity

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.