General Summary/Overview Statement:

The Physician Advisor is a key member of AtlantiCare’s leadership team and is charged with meeting the organization’s goals and objectives for facilitating complete and accurate clinical documentation in the medical record to support the diagnoses, treatment, medical necessity, severity of illness, and risk of mortality, which in turn substantiates accurate code and DRG assignment as well as assuring the effective, efficient utilization of health care services. The Physician Advisor serves AtlantiCare through teaching, consulting, and advising the medical staff, CDI, care management, utilization review, and coding departments as well as health system leadership teams. The Physician Advisor shall develop expertise on matters regarding compliance with governmental and private payer regulations and appropriate physician coding and documentation requirements as well as matters regarding physician practice patterns, over-and under-utilization of resources, medical necessity, levels of care, care progression, and denials management.  The Physician Advisor conducts clinical reviews on cases referred by the CDI specialist, CDI manager, coding, care management, and utilization review professionals, and Quality Officers to ensure clinical documentation meets regulatory requirements and adheres to coding specifications and guidelines as well the provision of quality patient care and effective utilization of resources. The Physician Advisor will interact with medical staff members to discuss the needs of the patients, alternative levels of care, and clinical documentation practices, and will serve as a liaison between CDI, coding, care management, and utilization review professionals and the organization’s medical staff to facilitate accurate and complete clinical documentation.

 

PRIMARY SCOPE OF SERVICE:

The Physician Advisor works closely with the medical staff leadership, the entire medical staff, including resident physician house staff, and coding and CDI to ensure physician clinical documentation is accurate and complete with respect to severity of illness, risk of mortality, and regulatory requirements with respect to coding specifications and billing guidelines.  In addition, the Physician Advisor also works with all areas of resource management, case management, social services, discharge planning, and utilization management to develop and implement methods to optimize use of hospital services for all patients while also ensuring the quality of care provided. This includes working with AtlantiCare’s hospital leadership in developing care management protocols with physicians and others to optimize length of hospital stay and efficient management of resources, ensuring patients are in the appropriate level of care, 

supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities. 

 

GENERAL REQUIREMENTS:

MINIMUM JOB SPECIFICATIONS:

Graduate of an accredited medical school and accredited residency program Minimum of five years of experience in clinical practice in a hospital setting Familiarity with MCG/Interqual placement status criteria is preferred Board Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) preferred. Possesses or acquires a solid foundation, knowledge, and/or experience in the areas of clinical documentation improvement, coding classification assignments, utilization management, responding to technical and substantive documentation and coding questions, and reimbursement methodologies Possess a working knowledge of AtlantiCare’s organization, operations (including case management), and administrative standards and policies Ability to build rapport with medical staff and AtlantiCare’s Health leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes Strong interpersonal skills Excellent communication skills (verbal, written, and listening) and ability to effectively present information, ideas, and concepts effectively to executive management, physicians, and employees Strong analytical skills Strong computer skills and working knowledge of the electronic medical record (EMR) Strong organizational skills and ability to set priorities and multi-task, demonstrates flexibility, teamwork, and is accustomed to change in the healthcare environment Demonstrates ability to drive results and produce outcomes

 

ORGANIZATION EXPECTATIONS:

Demonstrates behavior that supports the organization’s mission and tenets and the willingness to assume responsibility for the accuracy of its clinical documentation, clinical coded data, and the capture of severity, acuity, and risk of mortality Participates in required orientation and training related to the Physician Advisor role Meets production standards within established time requirements. Work product and performance meets quality standards

 

PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:

Educates medical staff regarding the correlation between clinical language and coding guidelines, severity of illness, risk of mortality, and DRG assignment and explains why 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/Hospital performance profiling (e.g., US News and World Report), physician E&M payment and pay for performance, appropriate hospital reimbursement Educates individual hospital staff physicians about ICD-10 and DRG 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 patients Educates medical staff (e.g., Internal Medicine, Surgery, Orthopedics, etc.) at departmental meetings on coding and documentation improvement guidelines and opportunities for clinical documentation improvement as well as shares data, trends, practice patterns, and other relevant information as requested Provides education to physicians and other clinicians on regulatory requirements, appropriate utilization of hospital services, community resources, and alternative level of care Provide education to physicians and other clinicians regarding inappropriate admissions and create action plans to address this issue Provides in-service education regarding medical conditions, for CDI specialists and HIM coding professionals as needed In collaboration with the Coding and CDI departments, develops, optimizes, and supports implementation of a clinical documentation improvement and integrity program that is integrated, engaged, and supportive of the clinical department and medical staff infrastructure, taking into account the makeup of the medical staff, the clinical process environment of AtlantiCare, and the overall strategic planning and goals of the organization Lists pitfalls to avoid in the development, optimization, and implementation phases of the CDI program that will jeopardize the probability of success in and buy-in from the medical staff Serves as the liaison between the health information department, the clinical documentation improvement and coding teams, the care management and utilization management teams, and the medical staff to encourage provider cooperation for complete and supportive documentation reflecting the patient’s condition as well as assist in length of stay management and appropriate utilization of resources discussions Reviews medical record and clinical documentation on a concurrent and retrospective basis and discusses clinical issues identified in record review activities (e.g., specificity of heart failure) as well as discusses clinical criteria for disease processes (e.g., sepsis or respiratory failure) Review medical records of patients identified by case managers or as requested by the healthcare team in order to perform utilization oversight Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews as well as assist with the denial management process Review cases that indicate a need for issuance of a hospital notice of non-coverage/Important Message from Medicare (HINN). Discuss the case with the attending physician and if additional clinical information is not available, coordinate the process with the Care Manager for issuance of HINNs Understand and use MCG/InterQual and other appropriate criteria. Document response to case management referrals. Support Case Management in a data-driven approach Facilitate pre-payment reviews and/or participating in recovery audit contractor reviews Assist Hospital Administration in billing for the technical component of the services rendered by the Departments, including initial billings, follow-up reports, and appeals in cases of retrospective denials Act as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate by participating in Peer-to-Peer discussions and reviews Participate 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 Participate in Interdisciplinary Rounds (IDT) with the Healthcare Team as indicated Provide guidance to ED physicians and ED Case Management regarding status issues and alternatives to acute care when acute care is not warranted Work with Care Management and the interdisciplinary team to ensure appropriate continuity of care Participate in all organizational efforts to reduce inappropriate readmissions Collaborates with coding and CDI professionals on a routine basis to review selected health records, explain clinical issues, and assist in developing appropriate and compliant provider queries Recommends and requests additional and more complete medical record documentation to support placement status or medical necessity Provides physician coaching and on-going education on appropriate clinical documentation, the importance of responding to queries, and assisting with the escalation of non-responded queries as appropriate Discusses how to recognize when a clinical query is needed with members of the CDI team Assists in facilitating broad communication of updated policies (payor-specific and internal) as needed Provides strategies to minimize risk and reduce provider liability or loss of inpatient revenue Documents patient care reviews, decisions, and other pertinent information Other duties as assigned

ADDITIONAL EXPECTATIONS AND RESPONSIBILITIES

Attend all meetings as requested by administration including participation in assigned committees, meetings, and other activities, such as hospital quality and performance committees (e.g., mortality review, LOS, readmission), medical audit and utilization review committees, quality assurance committees, and CDI and Coding committees Participate in the educational programs conducted by AtlantiCare to the extent necessary to ensure the Hospital’s overall compliance with accrediting and regulatory requirements Ensure the timely, accurate, and adequate completion of all medical records, including sufficient documentation of medical necessity and correct coding for the services rendered, in compliance with the Medical Staff Bylaws Participate in quality assessment and improvement activities Attend AtlantiCare sponsored education programs designed to promote adherence to laws, regulations, policies, and procedures relevant to the Physician Advisor Conduct presentations to Medical Staff, Hospital Board/Administration as warranted and related to Physician Advisor areas of expertise or knowledge

 

The above statements reflect the general duties and responsibilities necessary to describe the principal functions of the job, as identified, and shall not be considered an exhaustive list of job responsibilities which may be inherent in the job. Responsibilities are subject to change.