The physician advisor reports to the System Medical Director for Physician Advisory services and serves as a resource to the utilization review and care management staff on medical necessity, level of care, patient care progression, and denial management. This physician leader will act as consultant and resource to medical staff regarding their decisions related to appropriateness of hospitalization, continued stay, and appropriate use of resources.
Conduct status reviews, or secondary case reviews for individual patient cases or series of cases to assess medical necessity of hospitalizations or services, level of care determination and render a recommendation to attending provider.
Conduct peer-to-peer consults, or coordinate discussions with the payer medical directors for patient cases that have been denied, to resolve medical necessity issues prior to a claim submission.
Meets the health system's objectives for assuring quality patient care and effective, efficient utilization of healthcare resources while also meeting regulatory requirements.
Meets with care management and healthcare team members to discuss elective cases and make recommendations related to appropriate level of care and care progression.
Participate in case denial meetings to identify opportunities and decrease inappropriate denials
Interacts with medical staff members and payer medical directors to discuss the needs of patients, access to care and alternative levels of care.
Acts as consultant and resource to the CDI team for query facilitation.
Acts as consultant and resource to the transfer center team for challenging case reviews
Creates and presents analysis of short-term projects to explain claims and areas of opportunity to leadership and other associates
Act as educated to different levels of staffing and ongoing basis
Assist the System Medical Director for Physician Advisor services in achieving other goals like reducing avoidable length of stay, improve throughput and ensure responsible stewardship of clinical resources
Supports compliance with all state and federal regulations
Required Knowledge and Skills:
Knowledge of CMS/commercial insurance rules and regulations regarding medical necessity and appropriate use of resources
Strong organizational skills with attention to detail
Excellent analytical and problem-solving skills
Effective verbal and written communication skills
Proven capability to communicate on to develop positive relationships with medical staff, physicians, nurses, care managers and others
Proficient technical skills to include electronic medical record and computer software skills
Ability to understand, comply and advance CHRISTUS health strategic priorities, commitments, and values
MD or DO degree from an accredited medical school
5 years of experience in the clinical setting
2 years of experience in a physician advisor role or equivalent
2 years of experience in leadership and/or management roles
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.