Utilization Management Assistant Jobs in Michigan

The Physician Advisor is a key member of the healthcare organization's leadership team and is charged with meeting the organization's goals and objectives for assuring the effective, efficient utilization of health care services. The Physician Advisor is a physician serving the hospital through teaching, consulting, and advising the care management and utilization review departments and hospital leadership. The Physician Advisor shall develop expertise on matters regarding physician practice patterns, over and under-utilization of resources, medical necessity, levels of care, care progression, denial management, compliance with governmental and private payer regulations, appropriate physician coding and documentation requirements.
PRIMARY SCOPE OF SERVICE:
The Physician Advisor works closely with the medical staff leadership, medical staff, including resident physician house staff, all areas of resource management, case management, social services, 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. Supports the Revenue (Rev) Cycle, serving as a liaison between Rev Cycle and the medical staff members across the system, communicating with physicians and other health professionals This includes working with hospitals for efficient management of resources, insuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities.
The Physician Advisor reports directly to the: Medical Director if the Internal Physician Advisor Service (IPAS)
GENERAL REQUIREMENTS:
MINIMUM JOB SPECIFICATIONS:

• Doctoral degree in Medicine (M.D or D.O.)
• Hold and maintain an unrestricted medical license in the state of Michigan.
• Board Certification.
• Minimum five years of clinical practice.
• Meet the requirements (and become a member) of the Henry Ford Medical Staff.
• Possess or acquires a solid foundation, knowledge, and/or experience in the areas of utilization management, quality improvement, and patient safety.
• Possess a working knowledge of organization & case management operations and administrative standards and policies.
• Strong computer skills and working knowledge of EMRs (EPIC preferred).
• Familiarity with MCG/InterQual placement status criteria is preferred.
• Board Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) or the American College of Physician Advisors (ACPA-C) preferred.
• Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes

ORGANIZATION EXPECTATIONS:

• Demonstrates behavior that supports the organization's mission. Participates in required orientation and training related to the Physician Advisor role
• Meets production standards within established time requirements. Work productivity and performance meet quality standards.
• Demonstrates respect and uses positive interpersonal skills with patients, clients, the public, managers, and employees at all times.
• Maintains confidentiality of patient care and business matters.
• Adheres to all professional and performance expectations set forth within the medical staff bylaws, rules & regulations and complies with all Henry Ford established policies and procedures.
• Participate in ongoing training and education related to the Physician Advisor role and responsibilities including topics related to Utilization Management, Care Management and other related areas as requested.
• Obtains familiarity and working knowledge of standard published criteria such as MCG/InterQual and applies professional judgment and patient specific variables as may be necessary or justifiable.

CLINICAL EFFECTIVENESS:

• Demonstrates commitment to meeting/exceeding strategic initiatives of organization.
• Responds to requests for assistance on clinical reviews for medical necessity or any other reason, by any member of the Utilization Management (UM) department in a timely fashion.
• Upholds the organization's values of teamwork and professionalism and applies Code of Conduct standards to all members of the healthcare team.
• Provides consultation to nurses and case management staff regarding complex clinical issues and advises on justification required for continued stay, medical necessity and utilization management.

ESSENTIAL JOB DUTIES AND ACCOUNTABILITIES
ACUTE INPATIENT/CASE MANAGEMENT FUNCTIONS:

• Review medical records of patients identified by UM or as requested by the healthcare team to perform quality and utilization oversight
• Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews
• Perform Peer-to-Peer calls for inpatient and post-acute care denials
• Assist with length of stay management and utilization of resources
• Review and make suggestions related to resource and service management
• Provide regular feedback to physicians and all other stake holders regarding level of care, length of stay, and potential quality issues
• Recommend and request additional and more complete medical record documentation to support placement status or medical necessity
• Understand and use MCG/InterQual and other appropriate criteria. Document response to UM referrals. Support case management and physicians in the post-acute care process
• Assist Hospital Administration and the Medical Staff in connection with any regulatory audits, investigation, survey, or other review of the Departments
• Ensure consistency of utilization review services, quality control, and patient safety
• 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
• Facilitate, mentor, and educate other physicians regarding payer requirements
• Provide guidance to ED physicians and Access Care regarding status issues and alternatives to acute care when acute care is not warranted
• Participate in all organizational efforts to reduce inappropriate readmissions

PHYSICIAN SUPPORT, EDUCATION, AND COLLABORATION:

• Provide education to physicians and other clinicians related to regulatory requirements, appropriate utilization of hospital services, community resources, and alternative levels of care.
• Provide education to physicians and other clinicians regarding inappropriate admissions and create action plans to address this issue.
• Provide physician coaching and on-going education on appropriate clinical documentation improvement and care standards as may be appropriate.

PHYSICIAN LIAISON:
• Conducts physician education sessions to share data, trends, practice patterns, and other relevant information as requested.
• Works with hospital UM Medical Directors to:
o Ensures physician accountability for efficient patient care management.
o Investigates avoidable delay concerns referred by case management staff that affect patients' outcomes during their hospital stay.
o Contacts physicians in a timely manner to resolve delays and achieve positive outcomes.
o Demonstrates positive outcomes through interventions with attending or consulting physicians that delay care and affect the length of stay or avoidable delays, etc.
o Identifies denial trends and works with the medical staff and hospital administration to resolve the issue.
• Reports practice pattern trends and opportunities to service line or department specific meetings at the request of hospital leadership.
ORGANIZATIONAL PROCESS IMPROVEMENT:
• Promote and educate healthcare teams on a team approach to patient care. Promotes coordination, communication, and collaboration among all team members.
• Support the organization in quality improvement efforts requiring physician input and/or involvement.
MEDICAL INFORMATICS SUPPORT:
• Works with the IT Leadership team to ensure the system appropriately supports the physician's ability to provide best practice medicine by creating logical processes and providing the necessary order sets and practice guidelines.
• Participates in physician education and outreach efforts.
• Works in collaboration with the IT team to be sure all necessary physicians are trained, and training is appropriate for the physicians.
• Assists with order set development, review, and implementation to coordinate quality, efficiency, and utilization of the order sets, as requested.
ADDITIONAL EXPECTATIONS AND RESPONSIBILITIES
• Attend all meetings as requested by Revenue Cycle and hospital administrations and include Participation in assigned Hospital committees, meetings, and other activities, such as hospital quality and performance committees, medical audit and utilization review committees, and Hospital quality assurance committees.
• Upon request, actively participate in Hospital committees to develop protocols related to evidence-based medicine and support optimal standards of care.
• Participate in the educational programs conducted by the Hospital 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 risk management and quality assessment and improvement
activities.
• Attend (Hospital) sponsored education programs designed to promote adherence to laws, regulations, policies, and procedures relevant to Physician Advisor.
• Conduct presentations to Medical Staff, Hospital Board/Administration as warranted as may be related to Physician Advisor areas of expertise or knowledge.
• Assist with the evaluation of the hospital utilization management program, including adherence to the required CMS Conditions of Participation.
• Maintain current knowledge of federal, state, and payer regulatory and contract requirements.

• Attend continuing education sessions pertaining to utilization and quality management.

OUTCOMES AND DELIVERABLES:
• Documents education sessions for medical staff on trends, practice patterns, or relevant information.
• Tracts and reports Peer-to-Peer results where Physician Advisor intervention was required.