Onsite Physician Advisor

ACPM; San Antonio (TX); On-site; USD 140,000 - 210,000; Full time

Job summary

CHRISTUS Health in Irving, TX seeks a physician advisor reporting to the System Medical Director for Physician Advisory services. The role supports utilization review, care management, and denial management with a focus on medical necessity and appropriate resource use.

The successful candidate will conduct reviews, engage in peer-to-peer discussions with payers, and guide care teams on level of care and discharge planning, while maintaining regulatory compliance and quality outcomes.

Qualifications

• Knowledge of CMS/commercial insurance rules and regulations regarding medical necessity and appropriate use of resources.
• Strong organizational skills with attention to detail.
• Excellent analytical and problem-solving skills.
• Effective verbal and written communication skills.
• Proven capability to communicate to develop positive relationships with medical staff, physicians, nurses, care managers and others.
• Proficient EMR and computer software skills.
• Ability to understand, comply and advance CHRISTUS Health strategic priorities, commitments, and values.

Responsibilities

• Conduct status reviews and secondary case reviews to assess medical necessity, level of care, and provide recommendations to attending providers.
• Conduct peer-to-peer consults and coordinate discussions with payer medical directors to resolve medical necessity issues before claims submission.
• Meet health system objectives for quality care and efficient resource utilization while complying with regulations.
• Collaborate with care management and healthcare teams on elective cases and care progression decisions.
• Participate in case denial meetings to identify opportunities and reduce denials.
• Interact with medical staff and payer directors to discuss patient access and alternative care levels.
• Serve as consultant to the CDI team for query facilitation.
• Assist transfer center with challenging case reviews.
• Prepare analyses of short-term projects to explain claims and opportunities to leadership.
• Support system leadership in reducing avoidable length of stay and improving throughput.
• Ensure compliance with state and federal regulations.

Skills

CMS/insurance rules knowledge

Organizational skills

Analytical/problem-solving

Verbal/written communication

Interpersonal relationships with staff

EMR/computer skills

Understanding CHRISTUS priorities

Education

MD/DO degree

Board certification in clinical specialty

Job description

Description

Physician advisor reports to the System Medical Director for Physician Advisory services and serves as a resource to the utilization review and care management staff on medical necessity, level of care, patient care progression, and denial management. This physician leader will act as consultant and resource to medical staff regarding their decisions related to appropriateness of hospitalization, continued stay, and appropriate use of resources.

Key Responsibilities:

• Conduct status reviews, or secondary case reviews for individual patient cases or series of cases to assess medical necessity of hospitalizations or services, level of care determination and render a recommendation to attending provider.
• Conduct peer-to-peer consults, or coordinate discussions with the payer medical directors for patient cases that have been denied, to resolve medical necessity issues prior to a claim submission.
• Meets the health system's objectives for assuring quality patient care and effective, efficient utilization of healthcare resources while also meeting regulatory requirements.
• Meets with care management and healthcare team members to discuss elective cases and make recommendations related to appropriate level of care and care progression.
• Participate in case denial meetings to identify opportunities and decrease inappropriate denials
• Interacts with medical staff members and payer medical directors to discuss the needs of patients, access to care and alternative levels of care.
• Acts as consultant and resource to the CDI team for query facilitation.
• Acts as consultant and resource to the transfer center team for challenging case reviews
• Creates and presents analysis of short-term projects to explain claims and areas of opportunity to leadership and other associates
• Act as educated to different levels of staffing and ongoing basis
• Assist the System Medical Director for Physician Advisor services in achieving other goals like reducing avoidable length of stay, improve throughput and ensure responsible stewardship of clinical resources
• Supports compliance with all state and federal regulations

Required Knowledge and Skills:

• Knowledge of CMS/commercial insurance rules and regulations regarding medical necessity and appropriate use of resources
• Strong organizational skills with attention to detail
• Excellent analytical and problem-solving skills
• Effective verbal and written communication skills
• Proven capability to communicate on to develop positive relationships with medical staff, physicians, nurses, care managers and others
• Proficient technical skills to include electronic medical record and computer software skills
• Ability to understand, comply and advance CHRISTUS health strategic priorities, commitments, and values

Required Qualifications:

• MD or DO degree from an accredited medical school
• 5 years of experience in the clinical setting
• 2 years of experience in a physician advisor role or equivalent
• 2 years of experience in leadership and/or management roles
• Board-certified in a clinical specialty
• Board certification in HCQM (ABQAURP) preferred

Other Details:

Full time

Location - CHRISTUS Irving office

Willing to travel as needed

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