Physician Advisor of Utilization Review and Case Management

When you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives.

Job Type:

Regular

Scheduled Hours:

20

Work Shift:

Day (United States of America)

Position Summary: Reporting directly to the Chief Medical Officer (CMO), the Physician Advisor will play an active role in optimizing healthcare resource utilization, ensuring quality, patient care, and managing valuable organizational resources. The role will involve collaborating with key stakeholders of multidisciplinary teams-Nursing staff leadership, hospitalist and closely collaborates with the director of care transitions to assess and guide the appropriate utilization of medical services while maintaining compliance with all regulatory requirements.

The Physician Advisor is responsible for assisting the organization to challenge physician practices to achieve the organization's desired resource management and quality goals.

Job Description:

Purpose

Provide leadership and expertise relative to the level of care management, concurrent and retro commercial payer validation of medical necessity recommendations, as requested

Policy Setting Responsibilities

Responsible for utilization review and medical necessity recommendations, as requested

Decision-Making Authority:

Responsible for collaborating with the utilization review department as these issues relate to commercial payers, to meet established goals and for leading physician participation and compliance with responsibilities.

Supervisory Responsibility

Responsible for engaging physicians in utilization review and medical necessity activities

Key responsibilities

Utilization review and inpatient clinical optimization: (include all utilization review, patient status, observation, escalation, second level and peer to peer reviews.

• Conduct thorough medical review of patient cases to determine the medical necessity of services provided.

• Assess the appropriateness of treatment plans and interventions in accordance with clinical guidelines and best practice

• Collaborate with care teams to optimize, patient care, pathways, reduce unnecessary services, and promote efficient resource allocation

• Serves as physician expert and provide support to utilization review team regarding utilization decisions pertaining to commercial payors including screening for appropriateness of hospitalization, peer -to-peer discussions with payor provider representatives, participation in the observation escalation process, clinical reviews of utilization review activities.

FLSA Status:

Exempt

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more (~~~) about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled