Job Description
Description Position at Nuvance Health Summary: Provides physician leadership and expertise related to appropriate utilization/level of care (LOC) and appropriate clinical documentation. Provides oversight for other Physician Advisors for both the centralized denial prevention unit and the local hospitals. Collaborates with appropriate departments, leaders and committees to meet established goals for physician participation and compliance with expectations. Responsibilities: Provides physician leadership for physician advisors and physicians throughout the organization. Manages processes, policies, workflows and overall management of the physician advisor role within the organization. Works to lead standardization of policy, procedure and approach to physician advisor roles in utilization management, , documentation and denials/downgrades. Serves as physician expert and provides support to care team and denial prevention and denial management team members regarding utilization decisions including screening for appropriateness of hospitalization, LOC status, LOS management, continued stay decisions, clinical review of patients, utilization review activities, resource utilization/management, denial management issues, and potentially quality issues. Functions as a consultant and resource to other Physician Advisors and primary (attending) physicians. ;Assists Denial Prevention and Denial Management teams with complex cases requiring Physician Advisor expertise to support both peer to peers as well as creation and/or review of appeal letters to overturn retrospective denials. Supports care team to ensure appropriate patient placement, care/discharge/etc. Ensures medical staff have understanding and compliance with applicable areas of expertise. Provides instructional input and education to medical staff