Physician Advisor for Case Management and Regulatory Compliance

At Memorial Hermann, we pursue a common goal of delivering high quality, efficient care while creating exceptional experiences for every member of our community. When we say every member of our community, that includes our employees. We know that when our employees feel cared for, heard and valued, they are inspired to create moments that exceed expectations, while prioritizing safety, compassion, personalization and efficiency. If you want to advance your career and contribute to our vision of creating healthier communities, now and for generations to come, we want you to be a part of our team.

Job Summary

The physician or physicians occupying this role will review selected cases for appropriateness of admission, level of care criteria and continuing stay evaluation. In addition, the Physician Advisor will facilitate communication and problem resolution with attending physicians

The Physician Advisor works collaboratively with the Director of Case Management and the department staff, including Case Managers, Social Workers, and Resource Center staff. Position is appointed by MHMD and each hospital.

Job Description

Minimum Qualifications

Education:  Medical Doctorate (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school required; Additional education and experience in the areas of medical management, utilization management and quality improvement is preferred

Licenses/Certifications:  Licensed to practice as MD or DO in the state of Texas; Board certification in primary care or medical specialty area is preferred

Experience / Knowledge / Skills:

• Minimum six (6) years experience in hospital setting; Current staff privileges at one or more MHHS hospitals preferred
• Ability to work collaboratively to achieve established goals and exercise independent judgment with minimal supervision or oversight
• Recognition by peers as an outstanding clinician
• Proven capability to communicate and to develop positive relationships with physician colleagues
• Working knowledge of regulatory, payer and utilization management issues
• Demonstrated or early acquisition of expertise in documentation and coding
• Strong interpersonal, analytical, organizational, and communication skills
• Incumbent must demonstrate objectivity, flexibility and tact in dealing with potentially sensitive medical staff issues, practice patterns, and clinical resource utilization.

Principal Accountabilities

Case review

• Reviews individual cases, including denied cases, as requested by Case Managers to evaluate appropriateness of admission or continuing stay, utilizing standard published criteria adopted by MHHS as guidelines, and applying professional judgment and patient-specific variables.

Communication

• Serves as a member of the care management oversight team, acting as a primary physician liaison among hospital medical staff/practitioners, hospital management and MHHS.
• Communicates with physicians to capture additional pertinent information for appeal letter preparation.
• Communicates with attending physicians in order to resolve issues regarding appropriateness and resource utilization where interactions between attending physicians and case managers have not been effective.
• Coordinates and recommends local MHHS communication initiatives regarding medical management.

Compliance and efficiency

• Assisting MHHS in delivering the services provided in the Program in an efficient manner in compliance with applicable legal and accreditation requirements.
• Stays current on Medicare rules and regulations and applicable payer requirements.

Advocacy

• Advocates with staff for timely, efficient, appropriate and patient-centered care.

Assessment and monitoring

• Monitoring the clinical and business aspects of physician advising and utilization management activities.
• Reviews all routine reports and performance measures and prepares limited analysis for the purposes of informing leadership and educating staff.
• Makes recommendations to system, department and campus leadership regarding opportunities for improvement in patient care, clinical documentation practices, resource utilization and reduction of denials.

Collaboration with leadership

• Work collaboratively with the CM Director(s) on committee preparation, concerted approaches to utilization improvements for clinical services, complex or outlier cases, and standardization of routine reviews; and to ensure CMO(s) receive timely information and updates on the efforts of physician advisors.

Letters

• Formulates medical necessity appeal letters based on appropriateness of level of care.
• Reviews medical necessity appeals letters and follows the appropriate procedures.

Performance Improvement

• Assisting MHHS in the development, implementation and carrying out of performance improvement and quality assessment efforts for the Program.

Education

• Provides ongoing education and information to medical staff and case management staff regarding best practices, organizational structures and functions, use of clinical guidelines, appropriate levels of care, documentation, and relevant new regulation.
• Participates in care coordination pathway developments and workflow innovations.

Safety, Standards and Development

• Participation in relevant professional development organizations as approved by supervisor.
• Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
• Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermann’s service standards by providing safe, caring, personalized and efficient experiences to patients and colleagues.
• Other duties as assigned.