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Job Summary:

Functioning in an advisory capacity, utilizing an influential and collaborative approach with members of the medical staff to discuss the clinical management of cases referred by case management, clinicians and the care team to ensure appropriate level of care in compliance with state and federal regulations.  Provides education individually and in groups to physicians and care team to help to facilitate compliance with insurance regulations of medical conditions.

Position Responsibilities:

Concurrent Review of commercial denials, including inpatient case rate, inpatient per diem and SDS.  Identify cases appropriate for inpatient level of care and request peer to peer discussion with payer medical director.  Document outcome of peer-to-peer discussion to identify trends in commercial denial outcomes and report to medical director of utilization review. 

Review of non-commercial cases based on parameters set that represent high risk for audit.  Outreach to clinicians to discuss high risk cases and proper documentation.

Monitoring and managing observation length of stay.

Identify and address clinical over – or under-utilization trends, issues/barriers to discharge, delays in service with specific hospital or clinical departments, patient conditions or hospital-based processes.  Where appropriate, elevate to divisional Medical Director, Department VP, Physician Chair of Medical Management Committee, EVP Physician Services or other appropriate administrative or physician body for discussion and resolution through a formal performance improvement plan or initiative.  Refer all clinical quality issues to the Virtua divisional Quality Department and/or Medical Director.

Determine appropriate cases for appeal due to adverse outcome of peer-to-peer discussion and audits.  Review of Medicare/Medicaid RAC denials to select for written appeals.  Follow up of written appeal cases for both commercial and Medicare/Medicaid and recommendation for further action.

Participate in subsequent appeals activity as warranted.

Assist in the development and implementation of protocols, admission/discharge order sets, pathways or any other tools or strategies that assist the Virtua medical staff and care team in the delivery of quality care.  Identify focus for internal physician education opportunities.

Cross Coverage of Physician Advisors

Position Qualifications Required:

Required Experience:

2 years or more practicing as a physician specializing in inpatient hospital medicine (Hospitalist, ER, or medical sub specialist who concentrates on hospital medicine). Extensive knowledge of all of the medical specialties.

Required Education:

MD/DO degree

Training / Certification / Licensure:

Current NJ Medical License required.  Certification in Utilization Review or plan to become certified within two years of hire date.  Must be Board eligible or Board Certified in training specialty. Must be proficient in the use of technology to review clinical cases in EMR and document outcomes in UR IT system.