The Physician Advisor/Medical Director, Utilization Management works in conjunction with the CMO, Medical Directors, Care Management, Utilization Management, Population Health, Quality, Safety & Risk, and Health Information Management departments to assist in improving patient outcomes, pathway/guidelines, utilization, clinical documentation, preventing payor denials, and monitoring quality.

The role educates physicians and physician extenders (providers) about clinical documentation improvement (CDI), utilization management, quality, and statewide population health initiatives. May serve as Chair or physician lead in committees to meet routinely with leadership for the purpose of utilization management, quality, and population health. This position reports to the CMO.

Primary Responsibilities

• Advise and educate treating providers in the delivery of timely, appropriate, and cost-effective care.
• Address on an ongoing basis with clinical leads the performance and practice patterns of medical staff (including contract providers) concerning recognized criteria and indicators for the following: length of stay (LOS), inpatient days, observation hours, precertification, documentation, denials, and level of care appropriateness.
• Contacts and consults with attending and/or consulting providers:
  • regarding adverse determinations, alternate levels of care, and documentation requirements that prevent accurate coding and/or APR-DRG assignment.
  • to ensure appropriate documentation of Present on Admission (POA).
• Consult with clinical leads if attending does not concur with utilization review findings or documentation to support coding.
• Provides recommendations to providers on alternate levels of care to avoid non-reimbursable admissions and/or extended stays.
• Makes final decisions to render a letter of non-coverage if indicated.
• Reviews referrals from care managers and intervenes based on medical judgment to assign correct status and/or admission setting.
• Assists care managers in cases questioned for medical necessity of admission, extended stay, adequacy of discharge planning, and provision of quality care.
• Attends staff meetings.
• Meet regularly with department chairs to review query responses and potential financial impact to the organization with meeting progressing to a quarterly basis once an impact can be demonstrated.
• Reviews avoidable day, readmission, denials, cost per case and practice patterns for improvement opportunities and communicates it to the clinical leads.
• Acts as a liaison with various Medical Directors to reduce denials and improve patient outcomes.
• Conducts LOS meetings with care management staff weekly.
• Conducts complex case reviews.
• Collaborates with Executive Health Resources for reviews and RAC appeals as needed.
• Maintains current knowledge of CMS and Maryland regulations concerning utilization review, insurance, and discharge planning, as well as other healthcare legislation which may impact the department.
• Provides formal and informal education to medical staff regarding care management, documentation, and coding to include, but not limited to:
  • provider practice patterns, disease, and outcome management principles, and cost-effective strategies.
  • appropriate levels of care for select settings with emphasis on utilizing alternate levels of care when appropriate.
  • Use of Milliman MCGs and other payor criteria/guidelines, alternate rate contracts, and appeal activity.
  • policy changes and regulatory issues.
  • potentially preventable complications (PPC).
• Provides information regarding protocol/guideline development, implementation, and results.
• Attend CDI meetings to identify performance improvement opportunities in UM processes.
• Serves as a member of the Utilization Management Committee (UMC) and Population Health Council (PHC)
• Promote hospital adherence to ensure compliance with CMS policies regarding inpatient admissions and observation statuses and the appropriateness of continued hospital stays.
• Document clearly and concisely, following Shore Regional Health's policies and procedures, all interactions, interventions, and outcomes of physician advisor work in EPIC.
• Perform all other duties as assigned.