Medical Director, Clinical Physician Advisor

ID 2022-13473
Location
Administrative Services Building
Work Location
US-NC-Greensboro
Division : Name
Quality
Department : Name
SW-Quality Excellence Initiatv
Category
PROFESSIONAL/MNGMNT
Position Sub-Category
CLINICAL
Position Type
Full Time
Employment Type
Employee
Exempt/NonExempt
Exempt
FTE
1.00
Workforce Status
Hybrid II
Work Hours
40.00
Provider Schedule (specific schedule)
M-F
On call Required
No
Sub Category
Clinical

Overview

 

JOB SUMMARY

This leadership position acts to ensure the appropriate and efficient execution of Cone Health’s Physician Advisor program, including management of cases while assuring the quality of care is consistent, as related to the primary and secondary review process. The role will be accountable for leading the Clinical Revenue Cycle Work and to help educate clinical staff on issues related to appropriate documentation and coding. This medical director will continually develop and train the physician advisors and ensure appropriate denials management and utilization of system resources. The Physician Advisor medical director will chair the Utilization Management Committee and will serve as a thought partner and resource to members of the medical staff, clinical staff, utilization management team members, CDI team members, and Transitions of Care team members and higher-level leadership. This role will develop relationships with medical and clinical staff in order to understand and address their concerns and potential opportunities for improvement.
The Physician Advisor medical director will provide guidance on both an individual case and aggregate level to cultivate efficiency related to patient care delivery providing medical case review, utilization and quality review and submit recommendations, advice and liaison services concerning quality and cost-effective patient care.

 

EDUCATION REQUIREMENTS

Minimum education required:
Required:
MD or DO degree (or equivalent)
Board certified in areas of specialty

Preferred:
Physician Advisor Certification
Graduate of Physician Leadership Academy (Cone Health) or equivalent degree with education/preparation in healthcare administration and/or leadership development.

 

EXPERIENCE REQUIREMENTS

Required:
5 years of progressive clinical and administrative leadership demonstrating clinical skills, quality improvement, utilization management experience and team development.

Preferred:
1-3 years Quality Improvement
1-3 years Utilization Management

 

LICENSURE/CERTIFICATION/LISTING

REQUIRED
Licensed Physician MD/DO credential from the North Carolina Medical Board. License required and tracked by the local credentialing office
• A bachelor’s degree in chemistry or any related field.
• A four-year degree from an accredited medical school.
• Three to eight years of residency or internship programs.

PREFERRED Physician Advisor Certification from the American College of Physician Advisors preferred

 

ESSENTIAL JOB FUNCTIONS

• Identifies and leads utilization management/clinical revenue cycle improvement efforts for the enterprise. This includes:
• Developing and implementing best practices for denials management and utilization management efforts.
• Accountability for meeting/exceeding quality and financial goals set forth by the enterprise.
• Leading financial improvement efforts that decrease denials and improve revenue by educating clinical staff on documentation requirements.
• Reviews medical records of identified patients to assist with the level of care and length of stay determination.
• Interacts with medical staff members and medical directors of third-party payers to discuss the patient needs and alternative levels of care.
• Provides education to physicians and other clinicians on regulatory requirements, appropriate utilization of alternate levels of care, community resources and end of life care.
• Develops strategy and processes to reduce denials and audits. Assists with appeals. Reviews and offers suggestions related to resources and service management.
• Utilizes hospital data sources to identify and analyze patterns of over or under-utilization of services, quality metrics and makes recommendations towards achievement of those goals.
• Suggests recommendations of treatment of specific cases and discusses about the same to the health care team.
• Acts as consultant and resource to attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources.
• Reviews cases retroactively to determine appropriateness of Part B billing versus appeal.

KNOWLEDGE, SKILLS AND ABILITIES

Required:
-Knowledge of CMS/commercial insurance rules and regulations regarding medical necessity and appropriate use of resources.
-Strong communication, organizational, planning, problem-solving, technology, analytical, judgement and research skills.
-Build positive constructive relationships with physicians, nursing staff, TOC members, CDI team members and others.
-Proven past leadership accomplishments and experience in the field of physician advisory roles and/or clinical quality improvement.
-Demonstrate effective communication styles. Able to gain and sustain trust, hold accountability, while being comfortable with conflict.
-Strong self-awareness and able to listen deeply.
-Diplomacy while being decisive.
-Ability to command respect from medical staff, administration, and hospital staff.
-Results-oriented while being flexible and open-minded.
-Ability to understand, comply and advance Cone Health strategic priorities, commitments and values.
-Ability to work with and develop teams focused on driving outcomes related to financial performance, quality, and clinical excellence.

• Must be up-to-date on latest technologies and medical procedures.
• Excellent communication, problem solving and people skills
• Good knowledge in medical treatment methods.
• Documentation as required in EMR and/or revenue cycle software system

 

 

 

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