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This position is for qualified physicians seeking to enter the new and growing non-clinical practice specialty of Physician Advisor with a career trajectory towards a provider or payor medical director and beyond. This position drives performance across our organization by communicating with hospital physicians and utilization management staff at client hospitals to champion best practices for evidence-based care and its documentation. The Physician Advisor will be responsible for establishing, maintaining, and strengthening the relationship with Optum360 Physician Advisor Solutions client hospitals to appropriately optimize the use of Optum360 Physician Advisor Solutions services.

Training will be provided by Optum. The Physician Advisor will join a team of on-site physician advisors across the country.

Primary Scope of Service:

Although the Physician Advisor (PA) is employed by Optum, the intention is that the PA will become a key member of the client hospital's leadership team charged with meeting the organization's goals and objectives for ensuring the effective, efficient utilization of health care services. To this end, the PA will develop expertise on matters regarding physician practice patterns, over- and under-utilization of resources, medical necessity, documentation best practices, level of care progression, denial management, and compliance with governmental regulations and commercial insurance contracts.

The Physician Advisor will work closely with the medical staff, including house staff, hospital leadership, and all utilization management (UM) personnel to develop and implement methods to optimize the use of hospital services. This includes care management processes that insure patients are in the appropriate level of care with supporting documentation for regulatory compliance and accurate coding.

Primary Responsibilities:

• Conduct medical necessity reviews of cases referred by case management to ensure medical necessity and regulatory requirements are met for level of care
• Meet with case management, social work, and other healthcare team members to discuss selected cases and make recommendations regarding patient status
• Interacting with medical staff and medical directors of third-party payers to discuss the needs of patients and alternative levels of care
• Act as a consultant for the medical staff regarding their decisions for the appropriate level of care of hospitalized patients and supporting documentation
• Participate in the claims denial process, including appeals
• Review of utilization data to ensure hospital objectives for quality patient care
• Act as a resource for the medical staff regarding federal, state, and payer regulatory, quality, and contract requirements
• Serve as a physician member of the Utilization Review Committee, which may require non-clinical medical staff privileges application
• Provide education on utilization management topics (e.g. documentation) to the medical and UM staffs

Physician Advisor Will Not:

• Practice medicine during the hours scheduled, which includes:
  • Decision-making in a patient's plan of care or discharge
  • Write orders or prescriptions
  • Provide on-call coverage
• Set hospital clinical or administrative policies
• Supervise house staff or hospital employees
• Participate in any type of peer review (e.g. Quality, M&M)