CHRISTUS

St. Michael hospital and its affiliates through teaching, consulting, and advising both the Care Management Department and the medical staff on matters regarding physician practice patterns, documentation, over

and under-utilization of resources, medical necessity, compliance rules and regulations, collaboration and relationships with payers, and the community.

The PA also ensures physician support and execution for the Care Management and CDI Departments' initiatives by promoting effective and efficient physician documentation to support the patient's Level of Care (LOC), billing status, and appropriateness of Medicare Severity-Diagnosis Related Group (MS-DRG)/DRG assignment. The PA will submit monthly time records documenting time actually spent in the provision of the responsibilities outlined below. M-F, no call responsibilities! Reporting Relationship The PA reports directly to the Chief Medical Officer of St. Michael hospital

Texarkana Professional Qualifications The Physician Advisor-Care Management and Clinical Documentation Improvement role should be staffed by a physician with the following qualifications: 5 years of clinical experience Licensed physician in state of residence Board certified in a clinical specialty Certified by the American Board of Quality Assurance and Utilization Review Physicians, Inc (ABQUARP)•preferred Experienced in clinical practice with an understanding of utilization review Served on or chaired an Utilization Management Committee Demonstrated cost-efficient practice Physician Advisor•

Care Management & CDI Duties and Responsibilities Utilization Management Plan:

20%

In collaboration with the Director of CM, lead the Utilization Review Committee
Conduct secondary status reviews for appropriate level of care determination
Conduct peer-to-peer consults with the payor medical directors for the denied cases, to resolve medical necessity issues prior to claims submission.
In collaboration with the CMO and Director of CM, monitor key metrics for UM and participate in action steps to achieve targets. Metrics include (but not limited to):
Denial trends, appeals & recoveries
Length of stay
inpatient and observation
Condition Code 44

Physician & Staff Education:

15%

Provide education to physicians and other clinicians related to regulatory requirements, appropriate billing status and utilization of alternate levels of care, community resources, and end of life care.
Work with physicians to facilitate referrals to the continuum of care
Facilitate, mentor, and educate other physicians regarding payer requirements
Provide mentoring/coaching to UR Case Managers to increase knowledge in care progression
Educate physicians on the benefits and importance of a clinical documentation program and how to work with CDI specialists

Care Management:

50%

Participate in daily IDRs takes action to expedite testing and treatment to promote efficient patient care and appropriate LOC
Provides guidance/assistance to the Emergency Department Physicians and CM staff to ensure correct LOC designation at intake
Act as a liaison with payers to facilitate approvals and prevent denials or carved-out days when appropriate
Participate in review of long-stay patients escalated from Care Management to facilitate the use of the most appropriate LOC
Review cases that indicate a need for issuance of a hospital notice of non-coverage determination. Discuss the case with the attending physician and if additional clinical information is not available, discuss the process for issuance and appeal with the physician.
Document patient care reviews, decisions, and other pertinent information per hospital policy
Possess foundational knowledge of InterQual and MCG criteria
Participate in Care Management Leadership & staff meetings to help identify and progress toward departmental goals
Notify the Care Manager of any conflict of interest in reviewing a particular patient record. Assist with identifying a physician to review such record. Clinical Documentation Integrity 15%
Provide feedback to physicians in each service on clinical documentation using specific case examples/3

M Highlights/ Benefits:

Balanced professional and personal lifestyle Competitive compensation and benefits No state income tax Relocation assistance

Community Description:

Easy drive to Dallas Enjoy the lush green countryside, pine tree-covered hills and lakes. Year-round outdoor activities include golfing, hunting, fishing, camping, hiking, and boating. Excellent public and private schools

Recruiter Contact Information :

Liz Flippo Email :

EEO is the law

click below for more information: We endeavor to make this site accessible to any and all users.

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