Physician Advisor, Clinical Documentation Improvement & Utilization Management

Position: Physician Advisor, Clinical Documentation Improvement & Utilization Management (CDI/UM)

PRIMARY SCOPE OF SERVICE:
The Physician Advisor, CDI/UM works closely with the medical staff leadership; the entire medical staff, including resident physician house staff; and Coding and CDI to ensure physician clinical documentation is accurate and complete with respect to severity of illness, risk of mortality and regulatory requirements with respect to coding specifications and billing guidelines. In addition, the Physician Advisor, CDI/UM also works with all areas of resource management, case management, social services, discharge planning and utilization management to develop and implement methods to optimize use of hospital services for all patients while also ensuring the quality of care provided. This includes working with AtlantiCare's hospital leadership in developing care management protocols with physicians and others to optimize length of hospital stay and efficient management of resources, ensuring patients are in the appropriate level of care; supporting documentation, coding improvements and compliance; and monitoring the appropriate use of diagnostic and therapeutic modalities.

GENERAL REQUIREMENTS:

MINIMUM JOB SPECIFICATIONS:

• Graduate of an accredited medical school with a current medical license in the state of New Jersey.
• Meets the requirements of AtlantiCare's Health medical staff.
• Minimum of five years of experience in clinical practice.
• Familiarity with MCG/InterQual placement status criteria is preferred.
• Board certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) preferred.
• Possesses or acquires a solid foundation, knowledge and/or experience in the areas of clinical documentation improvement; coding classification assignments and utilization management, responding to technical and substantive documentation and coding questions; and reimbursement methodologies.
• Ability to build rapport with medical staff and AtlantiCare's Health leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes.
• Strong interpersonal skills.
• Excellent communication skills (verbal, written and listening) and ability to effectively present information, ideas and concepts effectively to executive management, physicians and employees.
• Strong analytical skills.
• Strong computer skills and working knowledge of the electronic medical record (EMR).
• Strong organizational skills and ability to set priorities, multitask, demonstrate flexibility and teamwork, and being accustomed to change in the healthcare environment.
• Demonstrates ability to drive results and produce outcomes.

 
ORGANIZATION EXPECTATIONS:

• Demonstrates behavior that supports the organization's mission and tenets and the willingness to assume responsibility for the accuracy of its clinical documentation; clinical coded data; and the capture of severity, acuity and risk of mortality.
• Participates in required orientation and training related to the Physician Advisor, CDI/UM role.
• Meets production standards within established time requirements. Work product and performance meet quality standards.

PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:

• Educates medical staff regarding the correlation between clinical language and coding guidelines, severity of illness, risk of mortality and DRG assignment. Explains why 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/hospital performance profiling (e.g., U.S. News & World Report), physician E&M payment and pay for performance, and appropriate hospital reimbursement.
• Educates individual hospital staff physicians about ICD-10 and DRG coding guidelines (e.g., co-morbid conditions, outpatient versus inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality and DRG assignments for their individual patients.
• Educates medical staff (e.g., Internal Medicine, Surgery, etc.) at departmental meetings on coding and documentation improvement guidelines and opportunities for clinical documentation improvement, as well as sharing data, trends, practice patterns and other relevant information as requested.
• Provides education to physicians and other clinicians on regulatory requirements, appropriate utilization of hospital services, community resources and alternative level of care.
• Provides education to physicians and other clinicians regarding inappropriate admissions and creates action plans to address this issue.
• Provides in-service education regarding medical conditions for CDI specialists and HIM coding professionals as needed.
• In collaboration with the Coding and CDI departments, develops, optimizes and supports implementation of a clinical documentation improvement and integrity program that is integrated, engaged and supportive of the clinical department and medical staff infrastructure, taking into account the make-up of the medical staff, the clinical process environment of AtlantiCare, and the overall strategic planning and goals of the organization.
• Lists pitfalls to avoid in the development, optimization and implementation phases of the CDI program that will jeopardize the probability of success in and buy-in from the medical staff.
• Serves as the liaison between the Health Information department, the clinical documentation improvement and coding teams, the care management and utilization management teams, and the medical staff to encourage provider cooperation for complete and supportive documentation reflecting the patient's condition, as well as assisting in length of stay management and appropriate utilization of resources discussions.
• Reviews medical record and clinical documentation on a concurrent and retrospective basis and discusses clinical issues identified in record review activities (e.g., specificity of heart failure), as well as discusses clinical criteria for disease processes (e.g., sepsis or respiratory failure).
• Reviews medical records of patients identified by case managers or as requested by the healthcare team in order to perform utilization oversight.
• Performs medical necessity reviews, including initial level of care, secondary reviews and continued stay reviews, as well as assisting with the denial management process.
• Reviews cases that indicate a need for issuance of a hospital notice of non-coverage/Important Message from Medicare (HINN). Discusses the case with the attending physician and if additional clinical information is not available, coordinates the process with the care manager for issuance of HINNs.
• Understands and uses MCG/InterQual and other appropriate criteria. Documents response to case management referrals. Supports Case Management in a data-driven approach.
• Facilitates prepayment reviews and/or participating in recovery audit contractor reviews.
• Assists hospital administration in billing for the technical component of the services rendered by the departments, including initial billings, follow-up reports and appeals in cases of retrospective denials.
• Acts as a liaison with payers to facilitate approvals and prevents denials or carved-out days when appropriate by participating in peer-to-peer discussions and reviews.
• Participates in review of long-stay patients in conjunction with the Care Management leadership, Care Management team and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care.
• Participates in Interdisciplinary Rounds (IDT) with the healthcare team as indicated.
• Provides guidance to ED physicians and ED Case Management regarding status issues and alternatives to acute care when acute care is not warranted.
• Works with Care Management and the interdisciplinary team to ensure appropriate continuity of care.
• Participates in all organizational efforts to reduce inappropriate readmissions.
• Collaborates with coding and CDI professionals on a routine basis to review selected health records, explain clinical issues and assist in developing appropriate and compliant provider queries.
• Recommends and requests additional and more complete medical record documentation to support placement status or medical necessity.
• Provides physician coaching and ongoing education on appropriate clinical documentation, the importance of responding to queries and assisting with the escalation of non-responded queries as appropriate.
• Discusses how to recognize when a clinical query is needed with members of the CDI team.
• Assists in facilitating broad communication of updated policies (payor-specific and internal) as needed.
• Provides strategies to minimize risk and reduce provider liability or loss of inpatient revenue.
• Documents patient care reviews, decisions and other pertinent information.
• Other duties as assigned.

ADDITIONAL EXPECTATIONS AND RESPONSIBILITIES:

• Attends all meetings as requested by administration, including participation in assigned committees, meetings and other activities, such as hospital quality and performance committees (e.g., mortality review, LOS, readmission), medical audit and utilization review committees, quality assurance committees and CDI and Coding committees.
• Participates in the educational programs conducted by AtlantiCare to the extent necessary to ensure the hospital's overall compliance with accrediting and regulatory requirements.
• Ensures the timely, accurate and adequate completion of all medical records, including sufficient documentation of medical necessity and correct coding for the services rendered, in compliance with the Medical Staff Bylaws.
• Participates in quality assessment and improvement activities.
• Attends AtlantiCare sponsored education programs designed to promote adherence to laws, regulations, policies and procedures relevant to the Physician Advisor, CDI/UM.
• Conducts presentations to medical staff, hospital board/administration as warranted and related to Physician Advisor, CDI/UM areas of expertise or knowledge.

WORK ENVIRONMENT
Potential for exposure to the hazards and risk of the hospital environment, blood-borne pathogens (including exposure to infectious disease), hazardous substances and potential injury.

Essential functions of this position are listed on the Assessment and Evaluation Tool.

REPORTING RELATIONSHIP
This position reports to the Vice President of Finance.

The above statement reflects the general details considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position.