Crozer Health System is seeking an internal medicine or family medicine physician advisor to help support case management at all system hospitals. The Physician Advisor is a key member of the healthcare organizations leadership team and is charged with meeting the organizations goals and objectives for assuring the effective and efficient utilization of health care services.
Acute Inpatient/Care Management Functions
Reviews patient census on a daily basis to validate level of care and identify target length of stay for each patient
Reviews medical records of patients identified by care managers or as requested by the healthcare team in order to:
Assist with the denial management process
Review and make suggestions related to resource and service management
Determine if professionally recognized standards of quality care are met
Provides feedback to attending and consulting physicians regarding level of care, length of stay, and quality issues. Seeks additional clinical information from the attending and consulting physicians. Recommends and requests additional, more complete, medical record documentation. Recommends next steps in coordination of care and evidence-based medicine indicators.
Documents patient care reviews, decisions, and other pertinent information. Documents response to case management referrals. Supports Care Management in a data-driven approach.
Responds to assigned payor denials and completes chart review and peer-to-peer in the defined time period. Facilitates, mentors, and educates other physicians regarding payer requirements. Review appeal letters and provide guidance on response to denials, as assigned. Review full medical records to determine if denials based on medical reasons are defensible.
Participates 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. Participates in patient rounds with the Healthcare Team as indicated.
Identifies patients who are appropriate for transfer to LTACH facilities and works with physicians to facilitate referrals as needed.
Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, alternative levels of care, community resources, and end of life care. Works with physicians to facilitate referrals to palliative care. Assists physicians with end of life and hospice care consultations when appropriate.
Hospital Process Improvement
Identifies quality, safety, patient satisfaction and efficiency issues leading to suboptimal care. Takes appropriate action to resolve.
Clinical Documentation Support
Educates individual hospital staff physicians about ICD 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 patient records.
Educates specific medical staff departments (e.g., Internal Medicine, Surgery, Family Practice, etc) at departmental meetings regarding:
Reasons why individual physicians should be concerned about correct disease reporting and the subsequent ICD code capture of severity, acuity, risk of mortality, and DRG assignment
Appropriate hospital reimbursement and profiling for patient care.
Ways to provide improved health record documentation that specifically affect ICD code assignment capture of severity, acuity, risk of mortality, and DRG assignment.
Review past denials with physicians to explain what can be done in the future to appropriately document medical necessity.
Board Certification preferred but not required
Valid PA license or eligible for licensure in the commonwealth of Pennsylvania
Minimum of 5 years of Clinical Practice Experience
Previous Utilization Management Experience in Acute Care Setting Preferred
Knowledge of CMS Regulations and Knowledge of Nationally Accepted Guidelines such as MCG and InterQual Preferred
Excellent Communication and Interpersonal Skills
Strong Organizational Skills with Ability to Multi-task and Set Priorities
To learn more about this position and other opportunities with Crozer Health, please contact Amal Elmogahzy, Director of Physician Recruitment directly via e-mail: Amal.Elmogahzy@crozer.org, or phone: 732-357-7054. Thank you