Care Progression Physician Advisor (on-site, central California)

A large health system in California, Sutter Health is looking for a Physician Advisor for our large hospital in Modesto.  Work closely with the CEO/CMO and Case Management director to move the needle!

Position Overview:
The Physician Advisor (PA) is a key member of the hospital's leadership team
charged with meeting the organization's goals and objectives for ensuring the
effective, efficient utilization of health care services. The PA will develop

expertise on matters regarding physician practice patterns, over- and under-
utilization of resources, medical necessity, documentation best practices, level

of care progression, denial management and compliance with governmental
regulations and conditions of participation and commercial insurance contracts.
The PA is responsible for establishing, maintaining and strengthening the
relationship with System Enterprise and the hospital to appropriately optimize
the use of Sutter Health Internal Physician Advisor Services (IPAS). The
physician Advisor will work closely with the medical staff, including house staff,
and all utilization management (UM) personnel, Care Management (CM)
personnel to develop and implement methods and strategies to optimize the
use of hospital services. This includes care management processes that ensure
patients are in the appropriate level of care with supporting documentation of
regulatory compliance and accurate coding. The Physician Advisor (PA)
conducts clinical reviews on cases referred by UM/CM staff and or other
healthcare professionals to meet regulatory requirements in accordance with
the hospital objectives for assuring quality patient care and effective, efficient
utilization of health care services. The PA meets with care management, UM
staff and health care team members and medical directors of third-party payers
to discuss the needs of patient's and alternative levels of care. The PA acts as
consultant to and resource for attending physicians regarding their decisions
relative to appropriateness of hospitalization, continued stay, and use of
resources. The PA further acts as a resource for the medical staff regarding
federal and state utilization and quality regulations. The PA will act as a liaison
between the CDI (Clinical Documentation Improvement) professional, HIM
(Health Information Management ) ,and the hospital's medical staff to facilitate
accurate and complete documentation for coding and abstracting of clinical
data, capture of severity, acuity and risk for mortality, in addition to Direct
Report Groups (DRG) assignment.

CERTIFICATION & LICENSURE:
• MD-Doctor of Medicine
• OR DO-Doctor of Osteopathy
• Unrestricted medical license in state of residence
TYPICAL EXPERIENCE:
• 3 years of recent relevant experience.
SKILLS AND KNOWLEDGE:
• Excellent interpersonal communication and negotiation skills.
A broad knowledge base of health care delivery and case management within a managed
care environment.
•
• Comprehensive knowledge of Utilization Review, levels of care, and observation status.
Some awareness of healthcare reimbursement systems: Health Maintenance Organization
(HMO), Preferred Provider Organization (PPO), Patient Processing Service (PPS),Centers
for Medicare and Medicaid Services (GR) Grouper (CMS) preferred.
•

Post-acute levels of care such as Home Health, Hospice, Advance Illness Management
(AIM), and Palliative Care. Skilled Nursing Facility (SNF), Long Term Acute Care (LTAC),
B&C, Sub-acute, Acute rehab.
•

• Proficient Knowledge of coding and DRG assignment process preferred.
Must be able to effectively communicate with, and promote cooperation and collaboration
between individuals including patients/families/caretakers, physicians, nurses and other
ancillary partners.
•

Ability to work independently and exercise sound judgment in interactions with physicians,
payers, and patients and their families.
•
Demonstrates commitment to service excellence in all patient, family and employee
interactions and in performing all job responsibilities.
•
Functions in a manner to promote quality patient care and assure a positive patient
experience.
•
• Excellent verbal and written communication skills.
Must have excellent time management skills to develop organized work processes in a
high-volume environment with rapidly changing priorities.
•
• Intermediate computer skills.
• Ability to promote teamwork and to effectively function in teams.
Ability to interact effectively with key internal and external constituents using collaboration,
and customer service skills that promote excellence in the patient experience.