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).

Required Skills:

• 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

      Appeals Unit:

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.