Physician Advisor - Baptist Health Princeton Hospital

The Physician Advisor (PA) will act as a liaison between the medical staff, revenue cycle, physician leadership teams, and hospital administration, ensuring the system is optimized for regulatory compliance, medical necessity, and efficient utilisation of healthcare services. The PA conducts clinical reviews in accordance with the hospital’s objectives for quality patient care and effective clinical documentation.

Responsibilities:

• Meet with care management and healthcare team members to discuss cases and make care recommendations, interacting with medical staff and medical directors of third-party payers to address patient needs and alternative care levels.
• Serve as a consultant and resource for providers regarding hospitalisation appropriateness, continued stay, and resource utilisation.
• Act as a resource on federal and state utilisation and quality regulations.
• Review medical records as a second-level reviewer for cases identified by care managers or upon request by healthcare or administrative teams.
• Assist with patient status determination (level of care) and length of stay management.
• Support the denial management process.
• Review resource and service management, providing suggestions as needed.
• Assist staff with clinical reviews of patients and ensure standards of quality care are met.
• Optimise observation rates and length of stay.
• Provide feedback to providers on care level, length of stay, and quality issues, requesting additional documentation when necessary.
• Review cases requiring hospital notices of non-coverage or Medicare notices, discussing with physicians and managing appeals processes.
• Document reviews, decisions, and pertinent information in the electronic health record (EHR), using criteria like InterQual.
• Notify care managers of conflicts of interest and assist in identifying alternative reviewers.
• Facilitate approvals with payers, mentor providers on payer requirements, and prevent denials.
• Participate in reviews of long-stay patients and facilitate appropriate transfers to lower levels of care.
• Provide guidance to emergency department physicians and care management on status issues and alternatives to acute care.
• Work with teams to ensure continuity of care and reduce readmissions.
• Educate providers on regulatory requirements, utilisation, and community resources, including end-of-life care.
• Assist with end-of-life, palliative, and hospice care consultations as appropriate.
• Identify quality, safety, satisfaction, and efficiency issues, taking actions to resolve them.
• Promote team-based patient care and improve communication among healthcare team members.
• Support clinical documentation and quality improvement initiatives requiring physician input.
• Educate hospital staff on ICD coding and clinical terminology to improve documentation accuracy.
• Collaborate with EHR and quality teams to optimise system support for best practices.
• Participate in physician education, outreach, and advisory councils.
• Assist with order set development and review to enhance quality and efficiency.
• Maintain current knowledge of insurance regulations and quality metrics.
• Avoid reviewing their own patient assignments in an advisory capacity.
• Maintain punctual attendance and compliance with hospital policies and relevant laws.
• Participate in hospital committees, peer reviews, and utilisation management evaluations.
• Stay updated on regulatory and contractual requirements, attending relevant continuing education.
• Assist with denials, appeals, and length of stay reduction initiatives.
• Serve as a champion for care management, social work, and multidisciplinary care teams.

Qualifications:

• Education/Training: Medical Doctorate degree required, with residency training completed at an accredited program. Additional education in quality and utilisation management through CME and self-study.
• Licensure/Certification: Active Florida Medical License and certification as a Physician Advisor.
• Experience: Minimum of three (3) years of recent clinical practice experience.