Ochsner Health is hiring: Physician Advisor - Utilization Management in New Orle

We've made a lot of progress since opening the doors in 1942, but one thing has never changed - our commitment to serve, heal, lead, educate, and innovate. We believe that every award earned, every record broken and every patient helped is because of the dedicated employees who fill our hallways. At Ochsner, whether you work with patients every day or support those who do, you are making a difference and that matters. Come make a difference at Ochsner Health and discover your future today! The Physician Advisor (PA-Utilization Management) serves as the physician leader in matters relating to patient care. The PA will partner to reduce length of stay, ensure appropriate use of level of care determinations (inpatient, observation, outpatient, and other classifications as identified), support documentation and coding improvements and ensure organizational compliance in all areas. PAs facilitate communication across the patient care continuum (including the Interdisciplinary and Post-Acute teams, Payors, Administration and Revenue Cycle) to improve utilization management, sustain quality goals, and act as a consultant to physicians, administration, and case management to assure appropriate resource usage, document medical necessity, and comply with Federal and State regulations/quality initiatives. Reports to the System Medical Director of Utilization.This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at Ochsner's discretion.Training, Certification and SkillsMember of (1) American College of Physician Advisors (ACPA) or (2) Board Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or (3) Physician Advisor Sub-Specialty Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or (4) commitment to apply for such certificationsDemonstrated ability to build rapport with medical staff and hospital leadership.Comfortable having challenging conversationsStrong computer skills and working knowledge of EMRsDemonstrated ability to deliver high quality, cost-effective, efficient patient care servicesUtilization Management experience (preferred)Familiarity with: Current medical literature, Healthcare reimbursement issues (e.g., medical necessity, levels of care, coding), MCG / InterQual screening criteria, Medicare / Medicaid compliance, medical staff structure, policies and proceduresPhysician Advisors will have access to the required reports and data to make decisions, and to all pertinent federal, state regulations, laws, and policies and facilitate dissemination of relevant information to hospital clinical staff as appropriate.Essential Position DutiesCreate and Sustain PartnershipsPartner and collaborate with stakeholders in the support of appropriate management of patient care activities; Intercede on issues as needed to gain appropriate resolution (especially via direct with Provider communication; includes Case Managers, Coding, Revenue Cycle, Insurance Companies)Respond to requests for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management department in a timely fashion.Work with physicians on concurrent appeals (peer to peers)-discussions, appeals and denialsServe as an education resource to clinical and non-clinical personnel regarding medical necessity and regulations. (to include administration, providers, and operations teams)Work side by side with case managers, giving direction and education on patient process flow and provide support to foster trust within medical staffManage Patient FlowPerform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviewsAssist with length of stay management and utilization of resourcesAssist with the denial management processReview medical records of patients identified by case managers or as requested by stakeholders to perform quality and utilization oversightProvide regular feedback to physicians and all other stake holders regarding level of care, length of stay, and potential quality issuesRecommend and request additional complete medical record documentation to support placement status or medical necessityProvide direction and support for issuance of a hospital notice of non-coverage/Important Message from Medicare (HINN).Understand and use MCG/InterQual and other appropriate criteria. Document response to case management referrals. Support Case Management in a data-driven approachFacilitate pre-payment reviews and/or participating in recovery audit contractor reviewsAssist Hospital Administration in appeals process for retrospective denialsAssist Hospital Administration and the Medical Staff in connection with any regulatory audits, investigation, survey, or other review of the DepartmentsEnsure consistency of utilization review services, quality control, and patient safetyAct as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate by participating in Peer-to-Peer discussions and reviewsParticipate in review of long stay patients, in conjunction with the Care Management Leadership, Care Management team, and other members of the multidisciplinary team to facilitate the use of the most appropriate level of careParticipate in Interdisciplinary Rounds (IDT) with the Healthcare Team as requestedProvide guidance to ED physicians and ED Case Management regarding status issues and alternatives to acute care when acute care is not warrantedParticipate in all organizational efforts to improve quality performance metrics including but not limited to inappropriate readmissions, length of stay and observation initiativesProvide recommendations on inpatient admissions, outpatient and observation services, or case not appropriate for hospital level servicesReview and / or sign condition code 44 casesIdentify and assist in removing barriers to dischargeProvide written summary of activities including, but not limited to: recommendations for patient status, evidenced based support for decision-making, overview of discussions with physicians, plan of care for patient, next steps for interdisciplinary team (if appropriate), and appeal letter.Serve as Improvement ChampionParticipate in and recommend Quality Improvement Initiatives relating to documentation improvement and patient placementLead coaching of physicians and new residents on information related to, but not limited to:Documentation quality and standardsLevel of care statusUtilization standardsParticipate/Co-Lead UM Committee effort at the hospital levelEducationParticipate in ongoing training and education related to the Physician Advisor role and responsibilities including topics related to Utilization Management, Care Management and other related areas as requestedIdentify & support education needs of the medical staff with regard to documentation, placement and utilization of resourcesOther duties as assignedOccasionally, other duties may be assigned that relate to the PA's competenciesPerformance and ReportingThe physician advisor will report to the Vice President of Medical Affairs. Performance of the physician advisor will be evaluated on metrics relating toVolume of work activity (esp: physician to physician interactions)Quality of interaction (e.g.: how it is perceived by the medical staff, other team members)Utilization process metrics (e.g.: avoidable days, conversions)Hospital throughput metricsAppropriate compensating metrics (e.g.: early readmissions)The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time.Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.Complies with the Ochsner Health System Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns.Ochsner is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.Are you ready to make a difference? Apply Today!Ochsner Health does not consider an individual an applicant until they have formally applied to the open position on this careers website.Individuals who reside in and will work from the following areas are not eligible for remote work position: Colorado, California, Hawaii, Maryland, New York, Washington, and Washington D.C.Ochsner Health endeavors to make our site accessible to all users. If you would like to contact us regarding the accessibility of our website, or if you need an accommodation to complete the application process, please contact our HR Employee Solution Center at 504-842-4748 (select option 1) or careers@ochsner.org. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications.We are proud to be an Equal Employment Opportunity and Affirmative Action employer. We are committed to the principles of equal employment opportunity and providing a workplace that is free from discrimination based on race, color, creed, religion, pregnancy status, pregnancy-related conditions, national origin, ancestry, mental or physical disability, medical condition, age, veteran status, military status, citizenship status, marital status, familial status, sexual orientation, gender, gender identity or expression, genetic information, political affiliation, unemployment status, or any other characteristic protected under applicable federal, state or local law. These protections extend to applicants and all employment related decisions. View the EEO is the Law poster and its supplement, as well as the pay transparency policy for more information. Affirmative Action Policy Statement