St. Mary's Health Care System (SMHCS) has an excellent full-time employment opportunity for a Board Certified Acute Care Utilization Review Physician Advisor located in Athens, Georgia.

Through a dyad leadership structure, the Physician Advisor develops and educates providers and other clinicians on matters related to medical necessity and associated clinical documentation, level of care progression, and denials management. This work is done in collaboration with the case management (CM) and health information management (HIM) department leaders, and other key members of those departments, to develop and implement methods and strategies to optimize the use of hospital services and coding. Also works with leaders and key stakeholders involved in the revenue cycle and payer strategies, to reduce denials and protect reimbursement.

Essential functions of this role include:

• Conducts clinical reviews on cases referred by 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.
• Acts as consultant to and resource for attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources.
• Serves as a resource for the medical staff regarding federal and state utilization and quality regulations.
• Responsible for establishing, maintaining, and strengthening the relationship with key stakeholders, including providers, senior leaders, department leaders and colleagues, to appropriately optimize the use of the physician advisor services.
• As  requested, acts as a liaison between the health information management department's clinical documentation improvement professionals and the hospitals 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 DRG assignment.
• Work closely with the medical staff and all utilization management (UM) personnel, to develop and implement methods and strategies to optimize the use of hospital services. This includes UM processes that ensure patients are in the appropriate level of care with supporting documentation of regulatory compliance and accurate coding.
• Participates in third party payer meetings, as requested, and offers feedback for third party payer contract management services, as requested.
• Meets with interprofessional team members to discuss the needs of patients and alternative levels of care.
• Performs denials management related services, including verbal and written appeals, with medical directors of third-party payers.
• Proponent and champion for organizational standardization and consistency in order to develop a fully integrated delivery system that aligns with St. Mary's Mission, Vision and Values.
• Provides clinical direction for development and implementation of chronic condition care management programs, including integration of and compliance with payor mandated procedures, coordination of referral processes, and comparison to benchmarks of all utilization data and timely reporting of same to staff and management.
• Provides administrative physician leadership for certain provider support services, including maintenance of timely physician and non-physician payor and facility credentialing, and coordination of the clinical aspects of professional liability issues.

Requirements for this opportunity include:

• MD or DO degree
• Board certification in primary specialty
• Active Georgia License
• Additional advanced degree desirable (MBA, MPH, MMM, etc.)
• Ten years of clinical experience preferred
• Two years of utilization management/physician advisor experience preferred
• Experience with InterQual, MCG and Midas preferred
• Business and/or Operational Management experience preferred
• Demonstrated leadership, people management, and team building skills
• Ability to develop and implement strategic clinical plans
• Excellent oral and written communication 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: HMO, PPO, PPS,CMS preferred.
• Knowledge of coding and DRG assignment process preferred.
• Must have excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.
• Ability to interact effectively with key internal and external constituents using collaboration, and customer service skills that promote excellence in the patient experience.
• Excellent negotiation skills
• Customer service oriented
• Demonstrated confidence, initiative, and integrity in work practices
• Goal-directed and well organized
• High level of dependability and accuracy
• Ability to work independently
• Adept at conflict management
• Ability to function within a stressful environment
• Strong computer skills and working knowledge of EMRs

This is an excellent opportunity for an outstanding physician to join the St. Mary's Health Care System team.

RECRUITMENT PACKAGE

St. Mary's Health Care System offers a comprehensive salary and benefits package.