The Physician Advisor serves as a physician resource to the Centralized Appeals Unit of Trinity Health Mid-Atlantic, Mercy Fitzgerald Hospital. Reporting to the Chief Medical Officer, the Physician Advisor provides excellent and timely follow up of communication amongst patients, families, care managers, physicians, and payors to include peer-to-peer discussion and clinical documentation opportunities while demonstrating the ability to facilitate and de-escalate difficult conversations in a professional manner. The Physician Advisor respects and values the contributions of all disciplines and builds collegial relationships that foster trust and confidence by demonstrating credibility and problem-solving skills serving as a mediator amongst different departments, teams, or individuals involved with the patient’s episode of care.
Responsible for providing physician expertise regarding the centralized appeal of payer downgrades and denials for medical necessity at all levels of care for managed care, Medicaid and Medicare (precertification, concurrent and retrospective, Medicare Redetermination, Medicare Reconsideration and Medicare Administrative Law Judge Hearings appeals).
Reviews may be performed using a variety of means, including but not limited to telephonic “Peer to Peer" reviews, formal written appeals, electronic appeal, in person meetings or formal hearings, including Medicaid Bureau of Hearings and Appeals and Medicare Administrative Law Judge Hearings).
The Physician Advisor, Centralized Appeals Unit works with other Centralized Appeals Unit colleagues as well as hospital and system medical staff, case management, billing, quality, compliance and others, and shall be an expert in regulatory guidelines, medical necessity guidelines, documentation requirements and successful coordination techniques with internal and external utilization management ("UM"), physician advisors and medical staff.
Works collaboratively to achieve the stated goals of the Centralized Appeals Unit including reduction of denials and downgrades, enhanced recovery of denied/downgraded revenues and recovery timeframes, proactive outreach to payers and providers on streamlining the denial/downgrade appeal process, improved documentation and increased coordination of care.
Accomplishes this through direct engagement of the Centralized Appeals Unit staff, case management, medical staff and payers and by contributing to the development of pertinent documentation in the UM and appeals management process.
Participates in each operating unit’s Utilization Review Committee, medical staff meetings, payer meetings and other meetings as assigned.
Provide cross coverage as needed for the hospital-based Physician Advisors for vacations and sick time, and provide additional clinical expertise when a Physician Advisor conflict exists (Physician Advisors cannot review patients if there is a financial interest in the group being reviewed).
Excellent customer service and interpersonal skills
Conducts data analyses using strong analytical skills
Utilizes data in performance improvement activities
Able to effectively present information, both formal and informal
Strong written and verbal communication skills with all levels of internal and external customers
Strong organizational skills, ability to set priorities and multi-task, listening skills, flexibility/openness to change
Use of MIDAS, EMR, or Veracity (documentation and reporting), word processing, general knowledge of office procedures and equipment including copier, computer, and fax machine
Outcomes and Deliverables:
Completes appeals in accordance with established timeframes
Submits monthly/quarterly record of own performance to the Medical Director, Centralized
o Appeals success rate and clinical denial/appeals summary including progress towards target/goal
o Quarterly written articles in organizational newsletter on appeals management
Minimum Job Requirements/Experience:
D. or D O. degree with current Pennsylvania licensure, board certified preferably in internal medicine (minimum 3-5 years working experience as a practicing physician).
Direct experience with Health Plan/Payer Utilization Review and appeals process.
Working knowledge of InterQual and/or Milliman preferred.
Trinity Health is one of the largest multi-institutional Catholic health care delivery systems in the nation. We serve people and communities in 22 states from coast to coast with more than 90 hospitals and 100 continuing care facilities – including home care, hospice, PACE and senior living facilities and programs that provide nearly two and a half million visits annually. Trinity Health employs more than 133,000 colleagues, including 7,800 employed physicians and clinicians.
Our mission: We, Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities. We support this mission by living our core values of Reverence, Commitment to Those Who are Poor, Justice, Stewardship, and Integrity. Committed to recruiting talented physicians, we are looking for physicians who share our values and want to help us fulfill the health care needs of the communities we serve.
At Trinity Health, we value the physician relationship and focus on partnering with our physicians. Whether you are a practicing physician looking to relocate or a medical resident, we offer opportunities with the flexibility to fit your indivi...dual needs. If you would like to be part of Trinity Health, we encourage you to explore this opportunity at www.trinity-health.org