Description

1. The Physician Advisor serves the Hospital through collaborating with, advising, and teaching the Care Coordination Department; serving as a member of the medical staff; and coordinating with Hospital leadership on matters regarding progression of patient care, medical necessity, compliance with regulatory guidelines, payer relationships; clinical documentation integrity, and identification of trends in the over and under-utilization of resources.

2. The Physician Advisor should be a key member of the medical staff and take on the role as leader of the Hospital's utilization review/management committee, which is charged with adhering to regulatory requirements while ensuring high levels of healthcare quality and acceptable levels for the cost of care.

3. The Physician Advisor will conduct clinical reviews on cases referred by case/utilization management and/or other healthcare professionals in accordance with Hospital objectives related to quality care of patients, regulatory compliance, and utilization management (including LOS).

4. The Physician Advisor should discuss his/her role with the Hospital CMO, or similar position, to clearly define expectations and mentorship opportunities. Specifically, the Physician Advisor will be expected to work in close partnership with CommonSpirit Health's Internal Physician Advisor Services (IPAS) to ensure continuity of services provided.

5. Additionally, the Physician Advisor will be expected to understand and appreciate the unique elements of a Hospital's culture, history, and place in the community it serves. All work should be aligned with CommonSpirit Health's Mission, Vision, and Values.

6. Because of the importance of the role of the Physician Advisor and the visibility this role brings, it is expected that the Physician Advisor has a minimum of 5-7 years of leadership experience (or equivalent experience) in inpatient and/or advisory settings and possess the appropriate credentials in good standing.

Key Responsibilities

ESSENTIAL JOB FUNCTIONS:

CLINICAL EFFECTIVENESS:

• Lead in clinical process design/improvement sessions
• Collaborate with stakeholders in the development of a compliant and efficient Care Delivery Model (CDM) VMMC
• Provide clinical expertise related to medical necessity claims Job Title: Physician Advisor Job Code: Dept:
• Collaborate on the development and implementation of standard Clinical Care Pathways for defined diagnoses and DRGs
• Review issues identified by Care Coordination to ensure appropriate follow-up, recommends improvement initiatives as needed and makes suggestions to providers and appropriate department chairs as necessary
• Provide consultation to Care Coordination staff regarding complex clinical issues and advises on next steps
• Documents patient care reviews, decisions, and other pertinent information per Hospital/Utilization Management policy

COLLABORATION:

• Establish and champion successful relationships with Care Coordination (Utilization Management, Denials Management, and Progression/Transition of Care)
• Establish partnership and communication channel with attending physicians
• Create strategies to enhance Hospital and post-acute interdisciplinary efforts for maximizing patient/family outcomes
• Collaborate with medical staff in the development and measurement of performance standards involving patient care and utilization of resources to achieve optimal outcomes
• Notify the case manager of any conflict of interest in reviewing a particular patient record
• Collaborate with Care Coordination as needed for Hospital cases that may need issuance of a Hospital notice of non-coverage.

UTILIZATION MANAGEMENT:

• Take ownership of onsite Condition Code 44 process
• Assist with Readmission reduction - focusing on 30 days, all causes
• Assist with the segmentation of concurrent review offerings into Medicare / Medicaid / Commercial Payors, as needed
• Reviews medical records of patients identified by case managers/utilization review nurses, or as requested by other members of the healthcare team, in order to:
• Assist with patient status determinations and length of stay management (LOS)
• Assist with the identification and management of denials
• Make suggestions related to resource utilization and service management
• Determine if standards of quality care, as defined by the Hospital's Medical Executive Committee (MEC), are satisfied
• Provide feedback to attending and consulting physicians regarding patient status, length of stay, and quality issues
• Seek additional clinical information from the attending and consulting physicians as required to make effective patient status determinations, and in doing so, recommends and requests additional, or more complete, medical record documentation to support such determinations
• Actively participate in the Hospital's claim denial process, including, but not limited to responding to denials from payers on a concurrent basis; authoring denial letters as needed on retrospective denials; and determining to what extent denied cases will be appealed
• Focus on concurrent medical necessity denials
• Participate in audits by CMS, RAC entities, or other agents as required
• Participate in the utilization review/management committee, in defining operational strategic objectives for the Utilization Management Program and serves as the liaison to other medical staff committees that interface with the utilization review/management committee
• Assists with the evaluation of the Hospital's Utilization Management Program
• Assist with appropriate utilization of palliative care
• Participate in review of long-stay patients, in conjunction with the Director/Manager of Case Management and to facilitate determination of the most appropriate patient status at any given time.
• Round daily on the patient care units, and throughout the Hospital, to identify opportunities to impact resource utilization and manage length of stay (e.g., outliers, medical management practices, problematic patient/family dynamics). Typical rounding would be MDRs (multidisciplinary rounds).
• Participate in daily engagement huddles

PHYSICIAN LIAISON:

• Discuss cases with the attending physician and whether additional clinical information is available or not
• Provide education to physicians and other clinicians related to appropriate utilization of alternate levels of care and community resources
• Work with physicians to facilitate appropriate discharges across the continuum of care
• Facilitate, mentor, educate other physicians regarding payor requirements and CMS guidelines for medical necessity
• Conduct physician education sessions to share data, trends, practice patterns, and other relevant information as requested by Hospital leadership
• Ensure physician accountability for efficient patient care management
• Contact physician to resolve delays and achieve positive outcomes
• Communicate to medical staff leaders (e.g., department chairs, medical directors and other attending physicians as necessary) relevant findings of physician's performance when patterns of clinical outcomes demonstrate undesirable variation
• Act as consultant and resource to medical staff regarding federal and state utilization and quality regulations
• Act as physician liaison between case management/utilization management and providers to communicate the need for end-of-life care with patients and families where appropriate
• Liaise with Payer Strategy and Revenue Cycle regarding payer tactics and behaviors, as well as overall patterns and trends for reimbursement

CLINICAL DOCUMENTATION INTEGRITY (CDI):

Champion continuous CDI improvements and best practices Dept:

• Provide support and assistance to Clinical Documentation Specialists and Coders on an ongoing basis by:
• Addressing specific documentation issues encountered by CDSs/Coders, including non-compliant physicians
• Assisting in determining appropriate questions to ask physician
• Facilitating applicable approaches/interventions to use with physicians
• Determine the focus of presentations of clinical examples regarding documentation opportunities and specifics based on quarterly trends and presents this information in department meetings
• Update Hospital administration and medical staff leadership on changes in physician behaviors related to clinical documentation over time OTHER:
• Review and report on PEPPER metrics; (LOS, CMI, Re-admissions, OBS rates, and governmental audit measures) to Hospital leadership
• Support and/or perform the ALJ and DAB appeals process; especially ALJ support
• Demonstrate experience with multiple EMR/EHR; beneficial
• Patient Experience: Support improvement measures of HCAHPS percentile score for care transition measure - should be attached to facility/commonspirit targets
• Patient Experience: Support improvement measures of HCAHPS percentile score for discharge process
• Adhere to the standards of employee conduct for CommonSpirit Health

Competing Interests / Exclusions:

Because the Physician Advisor in this position will have access to extraordinarily sensitive and confidential information of the Hospital, it is understood that the Physician Advisor may not during his or her term in this position take on the following roles outside the CommonSpirit Health system:

• Be a medical staff leader or medical staff officer
• Department chair
• Medical staff executive committee member
• Corporate board member
• Service chief at any other health care facility (Hospital, surgery center, dialysis center, etc.)

Virginia Mason Franciscan Health has a rich history of providing exceptional healthcare, dating back to 1891. Building upon a legacy of compassionate care and innovation, our organization has evolved over the years through strategic partnerships and integrations to expand our reach and services across the Puget Sound area.

Today, as Virginia Mason Franciscan Health, we remain deeply committed to healing the whole person body, mind, and spirit in the communities we serve. This commitment is strengthened by the diverse expertise and shared values brought together through our growth.

Our dedicated providers offer a full spectrum of health care services, from routine wellness to complex disease management, all grounded in rigorous research and education. Our comprehensive network of 10 hospitals and nearly 300 care sites strategically located across the greater Puget Sound region reflects our ongoing commitment to accessibility and comprehensive care.

We are proud of our pioneering medical advances and numerous awards and accreditations that reflect our dedication to excellence. When you join Virginia Mason Franciscan Health, you become part of a team that delivers top-quality, professional healthcare in modern, well-equipped facilities, and contributes to a legacy of service built on collaboration and shared purpose.