Consultant

Qualifications

Doctorate Degree in Medical Field (Required)

Possess or acquires a solid foundation knowledge and/or experience in the areas of utilization management, quality improvement, clinical documentation improvement, and patient safety (Required)

Possess a working knowledge of Phoebe Health System organization & case management operations and administrative standards and policies (Required)

Strong computer skills and working knowledge of the EMR (Required)

Familiarity with MCG Interqual placement status criteria (Preferred)

Member of the American College of Physician Advisors (ACPA) (Preferred)

Board Certification by the American Board of Quality Assurance and Utilization Review Physicians Inc. (ABQAURP) (Preferred)

Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes (Required)

Ability to provide medical guidance and support to the VP of Patient Logistics and Care Coordination as well as the Director(s) of Care Management and Phoebe Care Command in meeting operational goals and strategic imperatives (Required)

Licenses and Certifications

Required Certifications/Licensures:

Medical Degree (Required)

Certified Clinical Documentation Specialist (CCDS) (Preferred)

Acute Care Functions

Review medical records of patients identified by case managers or as requested by the healthcare team in order to perform quality and utilization oversight

Provide guidance to ED physicians and ED Case Management regarding status issues and alternatives to acute care when acute care is not warranted

Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews

Recommend and request additional and more complete medical record documentation to support placement status or medical necessity

Facilitate, mentor, and educate other physicians regarding payer requirements

Provide regular feedback to physicians and all other stakeholders regarding the level of care, length of stay, and utilization of resources

Review cases that indicate a need for issuance of a hospital notice of non-coverage (Important Message from Medicare HINN)

Discuss the case with the attending physician and, if additional clinical information is not available, coordinate the process with the Care Manager for issuance of HINNs

Participate in the review of long-stay patients in conjunction with Care Management Leadership, Care Management team, and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care

Act 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 reviews, concurrently and retrospectively

Assist with the denial management process

Participate in all organizational efforts to reduce inappropriate readmissions

Understand and use MCG InterQual and other appropriate criteria

Document response to case management referrals

Support Case Management in a data-driven approach

Facilitate pre-payment reviews and/or participate in recovery audit contractor reviews

Assist Hospital Administration and the Medical Staff in connection with any regulatory audits, investigations, surveys, or other reviews of the Departments

Ensure consistency of utilization review services

Work with Care Management and an interdisciplinary team to ensure the appropriate continuity of care

Physician Support, Education, and Collaboration

Provide education to physicians and other clinicians related to regulatory requirements and appropriate designation of patient status for hospital services

Provide education to physicians and other clinicians regarding inappropriate admissions and create action plans to address this issue

Provide physician coaching and ongoing education on appropriate clinical documentation improvement and care standards as may be appropriate

Physician Liaison

Conduct physician education sessions on regulations regarding patient status determination

Contact physicians in a timely manner to resolve throughput delays

Demonstrate positive outcomes through interventions with attending or consulting physicians that delay care and affect the length of stay or avoidable delays

Identify denial trends and work with the medical staff and hospital administration to resolve the issue

Report practice pattern trends and opportunities to service line or department-specific meetings at the request of the CEO, CMO, Vice President of Patient Logistics and Care Coordination, Director of Care Management, or hospital leadership

Clinical Documentation Improvement and Medical Necessity Support

Educate individual hospital staff physicians about coding guidelines (e.g., co-morbid conditions, outpatient observation vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records

Educate specific medical staff departments (e.g., Internal Medicine, Surgery, Family Practice, etc.) at departmental meetings on coding and documentation improvement guidelines

Explain reasons why individual physicians should be concerned about correct disease reporting and the subsequent ICD code capture of severity, acuity, risk of mortality, and DRG assignment, such as physician performance profiling, physician E&M payment and pay-for-performance, appropriate hospital reimbursement, and profiling for patient care

Describe ways to provide improved health record documentation that captures severity, acuity, and risk of mortality

Develop, structure, and implement a clinical documentation improvement and integrity program, taking into account the makeup of your medical staff, medical process environment of the hospital, medical coder competency/skill sets, and overall strategic planning of the organization

Build strategies for Medicare Important Message compliance in collaboration with care management

Develop the skills for screening for medical necessity, ensuring the appropriate level of care, and properly constructing clinical queries using established guidelines

Provide strategies to minimize risk and reduce provider liability or loss of inpatient revenue

Build and expand upon strategies that contributed to the development and implementation successes of clinical documentation improvement

Effectively communicate physician-teaching points for immediate and future clinical case studies

Discuss the basis for discussing succinct points with physicians that stress the application of medical records documentation beyond claims data into administrative data

Discuss how to recognize when a clinical query is needed with members of the CDI team

Outcomes and Deliverables

Submit monthly record of performance metrics or data as requested to the CMO, CEO, and VP of Patient Logistics and Care Coordination

Maintain documentation of the number of interventions and resulting outcomes or decisions and provide data on a monthly basis

Document education sessions for medical staff on trends, practice patterns, or relevant information

Track and report appeal and denial results where Chief Utilization Officer's intervention was required