Medical Director Physician Advisor UM

AdventHealth Corporate

All the benefits and perks you need for you and your family:

• Benefits from Day One
• Career Development
• Whole Person Wellbeing Resources
• Mental Health Resources and Support

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Shift: Monday-Friday

Job Location: Remote

The role you’ll contribute:

The Physician Advisor provides primary support for Utilization Management (UM) and secondary support for Care Management (CM) departments and serves as a liaison between UM and CM teams and medical staff, as well as, the medical liaison for payor escalations. The Physician Advisor is responsible for educating, informing and advising members of the Utilization Management, Care Management, Managed Care and Revenue Cycle departments and applicable medical staff, as well as collaborating with other disciplines to assist in the improvement of clinical documentation, patient safety, and quality outcomes.

Through primary support of Utilization Management, the Physician Advisor is responsible for providing clinical review of utilization, claims management, and quality assurance related to inpatient care, outpatient care/observation stays and referral services. The Physician Advisor is an important contact for clinicians, external providers, contracted health insurance payors, and regulatory agencies. This individual also serves as the subject matter expert, providing clinical expertise and business direction in support of medical management programs, promoting the delivery of high quality, patient focused and cost-effective medical care.

The value that you bring to the team:

• The value that you bring to the team:

• Provides clinical support/validation for both Utilization Management and Care Management teams
• Provides education and serves as a resource to Medical Staff colleagues regarding best practices, Utilization Management and Care Management structures, and functions and use of clinical guidelines
• Develops and facilitates productive internal/external relationships with all physicians and constituents of Utilization Management and Care Management
• Provides suggested approaches to clarifying clinical questions when Utilization Management and Care Management staff interact with physicians, nurses, or other health professionals
• Maintains a positive and supportive relationship between the inpatient facilities, payors and physicians (hospitalist groups and primary care providers), and acts as the interdepartmental liaison for ACO activities and program development
• Provides guidance to clinical questions from Utilization Management staff involved in authorizations, concurrent review, and denials
• Assists with interpretation of specific application of medical necessity criteria
• Responsible for reviewing and authorizing inpatient (IP) days – performs secondary review escalations
• Evaluates IP utilization patterns - Overutilization of specific resources/testing as it relates to a specific service area
• Assists in formulation of reasonable clinical arguments to address any questions regarding level of care
• Coordinates and supports both concurrent (Utilization Management) and retrospective (Central Denial Service) clinical denial management by reviewing and making recommendations on appealed provider claims and makes determinations for appeals and grievances from patients; assists in drafting and submitting clinical denial appeals, as needed
• Develops Medical Director relationships with payors to have open communication and consistently meets with these individuals to have mutually beneficial conversations to improve denials, decrease days in A/R and increase clean claims rate
• Performs peer-to-peer discussions with payer Medical Directors and/or discusses cases with payer representatives to facilitate claim resolution and build payer relationships
• Collaborates with Chief Medical Officers and acts as a liaison between contracted Managed Care/Commercial payors related to managed care denials, Care Management and the Hospital’s Medical Staff
• Works in close coordination with the processes of the Utilization Management staff for continual process improvement and reporting
• Reviews denials data and trends and works with Managed Care contracting team and patient financial services to identify opportunities to address retrospective denials through the contracting process
• Reviews key performance indicators and progress to targets; reviews data and trends to identify opportunities for utilization improvement to positively influence practice patterns and address avoidable delays
• Serves as a resource for the Utilization Management (UM) Committee and shares observations, information and trends identified through data and case reviews
• Conducts regular, ongoing meetings with Care Management to ensure continuity and efficiency in the inpatient setting, as well as, educate on common problematic clinical issues
• Provides guidance to clinical questions from Care Management staff regarding appropriateness of placement in terms of patient’s clinical status/care needs
• Supports long stay meetings to effectively manage length of stay. Generates clinically sound alternative ideas and approaches to complex and/or long stay patients
• Provides multidisciplinary, “big picture” approaches that coordinate clinical, psychosocial, payor, financial and other needs
• Promotes communication of expected discharge date with multidisciplinary team, patients and families

The expertise and experiences you’ll need to succeed:

Minimum qualifications:

• Graduate of accredited Medical School
• Bachelor of Science
• Minimum of 5 years of experience in hospital medicine in acute care setting
• Current and valid license as a physician
• Board certified and eligible for membership on the Hospital medical staff
• Direct involvement with supporting the development of a Utilization Management and Care Management departments
• Knowledge of change management principles, methodologies, and tools

Preferred qualifications:

• Master's degree in Business or Healthcare Administration
• Two (2) years or greater experience as a Physician Advisor
• Prior experience with third party payors preferred
• Healthcare Quality and Management Certification (HQCM)