Physician Advisor, Quality Utilization Management

Physician Advisor, Quality Utilization Management

The Physician Advisor for Utilization Management (UM) plays a vital role in providing clinical and managerial support aimed at enhancing process efficiency and resource allocation within the hospital setting. Reporting directly to the Regional Medical Director, this position works closely with various teams, including CCC/DP and UR, as well as physicians and hospital leadership, to elevate medical quality, service delivery, and financial performance. Key responsibilities include staff education, leading UM committees, and assisting care coordinators, the Emergency Department, and overall hospital operations.

Key Responsibilities

• Clinical & Management Guidance
  • Offer specialized knowledge in UM, championing the hospital's objectives in process enhancement and resource management.
  • Assist care coordination nurses, UR nurses, attending physicians, and administrative leaders in UM activities.

Communication & Education

• Collaborate with physicians and surgeons to encourage appropriate resource utilization.
• Act as a physician leader and educator on topics such as clinical documentation, medical necessity, denial reduction, patient throughput, and discharge planning.
• Share documentation strategies with the team during daily SWAT meetings.

Operational Oversight

• Participate in daily rounds on patient floors and/or SWAT, addressing care delays and unnecessary tests or treatments.
• Lead the hospital's Utilization Review Committee, identifying trends and executing improvement initiatives.
• Utilize measurable metrics to assess the quality and cost-effectiveness of patient care.
• Facilitate communication between managed care/commercial payers and healthcare providers regarding benefit coverage, utilization review, and quality assurance.

Compliance & Best Practices

• Ensure adherence to URAC standards, CMS policies, and other regulatory guidelines.
• Advocate for evidence-based treatment plans and compliance with established care protocols.

Process Improvement

• Identify and eliminate avoidable delays in patient care, working with clinical teams to optimize processes.
• Implement comprehensive care plans, order sets, and discharge strategies to enhance care delivery and meet GMLOS objectives.

Documentation & Appeals

• Maintain accurate and thorough documentation of all UM activities within the organization's Care Management information system.
• Conduct or assist in concurrent appeals for denied or downgraded coverage decisions from payers.
• Analyze payer trends and denial patterns, collaborating with Regional Medical Directors to develop improvement strategies.

Collaboration & Strategy Development

• Regularly meet with the Regional Medical Director to formulate and execute regional strategies for UM enhancement.
• Work together on payer strategies to manage denials and address trends in payer behavior.

Peer Collaboration & Support

• Assist in the Peer-to-Peer Process.
• Collaborate with hospital administration and ancillary leadership to enhance operational efficiencies that affect care delivery.

Qualifications

• A minimum of 5 years in clinical practice.
• A collaborative approach to work.
• Strong leadership and communication abilities.
• Demonstrated capacity to work with hospital administration, clinical teams, and external stakeholders.
• Comprehensive understanding of utilization management, care coordination, and regulatory standards.
• Comfortable navigating challenging conversations.
• Interprofessional focus in work practices.

Licensure / Certification

• Medical license in the state of PA or eligibility for licensure.
• Board certification required.

Preferred / Desired Qualifications

• Membership in the American College of Physician Advisors.
• Previous participation in UR committees.
• Experience as a physician advisor is advantageous.