System Manager, Physician Advisor Status Determinations

Job Purpose / Summary:

As the System Manager, Internal Physician Advisor Services (IPAS) Status Determinations, this role has oversight and manages the process and a team of staff Physician Advisors (PA) that conducts clinical case reviews referred by utilization management staff and/or other health care professionals to meet regulatory requirements; and in accordance with the hospital’s objectives for assuring quality patient care and effective and efficient utilization of health care services. The PA team meets with utilization management, case management and other health care team members to discuss selected cases and make recommendations related to medical necessity and levels of care; as well as interacting with medical staff members and medical directors of third- party payers to discuss the needs of patients and the available options for the provision of appropriate and quality care.. The PA team acts as consultants to, and resource for, clinical providers (including attending physicians) regarding their decisions relative, but not limited to, appropriateness of hospitalization, clinical documentation, continued Inpatient stay, and use of healthcare resources. The PA team further acts as a resource for the medical staff regarding federal and state utilization and quality regulations. The PA team acts as a liaison advising the medical staff to ensure that the electronic health record is consistent with the care being provided. This team also helps facilitate training for the physicians to include Utilization Management principles and regulatory guidelines as it relates to status determinations.

The System Manager of the IPAS Status Determination team is, further, responsible for providing leadership and guidance to their respective physician advisor team(s) for optimal operational efficiency and effectiveness. They provide support for maintaining the highest standards expected of the CSH physician advisors, in accordance with the physician advisor’s respective job description. Leadership, guidance, and support will be delivered on an individual basis, as well as through the team setting to ensure cohesive, organized, and timely delivery of physician advisor services. The manager oversees and monitors for adherence to CSH and IPAS policies and procedures, as well as government (state and federal) regulations relevant to the physician advisor scope of work. Approximately seventy percent (70%) of the IPAS Status Determination Team manager’s time will be in a supervisory and/or training role to their respective physician advisor team(s). The other thirty percent (30%) is spent on special projects related to compliance, quality assurance, revenue cycle and denials where case reviews, charters or other such work may be mandated.

ESSENTIAL KEY JOB RESPONSIBILITIES

• Facilitates day to day Status Determination Team operations management, including:
  • Queue management and monitoring
  • Overseeing observation follow-up process
  • Monitoring PA metrics and remote work etiquette
  • Oversee weekly Retro PA assignments
  • Conducting Performance evaluations on direct reports
  • Overseeing all aspects of the Training Program within the IPAS Department
  • Run and hold Status Determination PA team meetings
  • Scheduling
    • Training
    • Recruiting
    • Holidays

● Supports and participates in System related work by:

• • Attending any and all UM Hub meetings
  • Providing education and involved in all QA processes (both internal and external)
  • Working with partnered vendors in the CPaSS program
  • Involved in any Revenue Cycle, Payer Strategy and Denials initiatives as they pertain to the Status Determination Team

• Conducts medical record review in appropriate cases for medical necessity of inpatient admission, need for continued hospital stay, adequacy of discharge planning and quality care management

• Understand the intricacies of ICD-9-CM, ICD-10-CM/PCS, MS-DRG, APR-DRG, and the Medicare Inpatient Prospective Payment System (IPPS) to make medical determinations on severity of illness, acuity, risk of mortality, and communicate with treating physicians in cooperation with the utilization team and health information staff.
• Serve as a liaison between the national Utilization Management and Care Management teams, medical staff, and medical executives to encourage physician cooperation and understanding of documentation importance
• Assist in communications of Internal Physician Advisor services in the hospital newsletters and other communication vehicles to further educate the medical staff
• Communicate feedback on program results to facility leadership (i.e. CMO, Care Management Directors, Quality
  Directors)
• Provides feedback and education to the Care Management and Clinical Documentation Departments through written and verbal communication as well as appropriate tracking and trending for process improvement efforts.
• Attends and participates in facility committee meetings, by invitation, as applicable, for example:

o Clinical Documentation Steering Committee
o Extended Length of Stay Rounds
o Utilization Review Committee
o Care Management Staff Meetings

• Contacts Attending Physicians: Makes face-to-face and telephonic/electronic contacts and presentations to all
  medical staff physicians and potential physician groups introducing referral services, new products and present
  product offerings.

Required Education and Experience:

● MD or DO required
● Minimum 3 years of related work experience as a Physician Advisor, required
● Minimum 5 years of experience in Clinical Practice, required
● Minimum 2 years of experience as an internal IPAS Physician Advisor II or external equivalent, required
● Minimum 3 years experience on internal IPAS Status Determination Team or external equivalent, required

Required Licenses and Certifications:

● Internal medicine; Emergency Medicine; Family Practice; Surgery; Pediatrics or OB/GYN.
● Unrestricted license in any field of medicine in one or more states.

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system.