Physician Advisor Full Time
AdventHealth Palm Coast
Location Address: 60 Memorial Medical Parkway, Palm Coast, FL 32164
Top Reasons To Work At AdventHealth Palm Coast
Immediate Health Insurance Coverage
Top Employer of Choice in Central Florida
Career growth and advancement potential
You Will Be Responsible For:
· Provides physician review of denials, and writes and submits clinical denial appeals when required
· Interfaces with, advocates for, educates and serves as a liaison
· with Medical Staff.
· Performs peer-to-peer discussions with payer Medical Directors and/or discusses cases with payer representatives to facilitate claim resolution and build payer relationships
· Utilizes clinical knowledge and experience, information science, data analysis, and interpersonal skills to support and represent the optimal denials recovery and prevention processes identified with all medical, clinical and ancillary departments
· Researches and responds to denials in a timely fashion and identifies trends through data analysis
· Responds to identified trends by recommending changes in practice and/or provider documentation to promote denial prevention initiatives
· Serves as a subject matter expert, providing clinical expertise and business direction in support of best practice, world class denial management and prevention strategies
· Adheres to AdventHealth Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies.
· Collaborates with quality initiatives and teams.
- Responsible for reviewing denial patterns to identify trends to focus on areas of improvement, developing specific strategies to enhance denial prevention and mitigation in a proactive manner with payers, physicians and AdventHealth systems.
- Works cooperatively with the entire Denial Management team to develop strategic process improvement that is standardized and consistently applied across all regions.
- Write and submit appeals at all levels as needed, regarding but not limited to; medical necessity, non-covered services, experimental care, authorizations, and inpatient/observation level of care related denials.
- Collaborates with payers regarding utilization and denial activities to develop and maintain a positive and supportive relationship.
- Secure, analyze and present data to payers that will assist in the denial prevention strategies, and will allow for an open honest dialog enhancing process improvement.
- Analyze payer data to determine in-house strategies for denial mitigation.
- Develops Medical Director relationships with payers to have open communication and consistently meets with these individuals to have mutually beneficially conversations to improve denial numbers, decrease days in A/R and increase clean claims rate.
- Analyzes denials data and trends to works with Managed Care contracting team and patient financial services to identify opportunities to address retrospective denials through the contracting process.
- Provides input on developing plans for physician education to meet identified needs and provides information to members of the medical staff and clinical departments on Denial Management and prevention utilizing specific data trends and analysis.
- Identifies opportunities for improving processes for collecting, analyzing and communicating performance improvement indicators pertaining to denials recovery and prevention.
- Participates in denials management and Utilization Management committees. Provides updates on denials trends, issues and remediation plans as possible.
- Utilizes data to determine potential quality issues to discuss with the physician groups, experimental denials that may require interventions from the supply chain, and LOS issues to discuss with Care Management as a denial prevention effort.
- Meet with clinical staff as necessary to create remediation plans for patient care that does not meet established care protocols, has insufficient documentation, or deviates from payer or regulatory policies/standards.
- Actively reviews and acts upon trends identified through data analysis. Provides trend data of denials to assist in improving payer or care delivery behavior to the appropriate owners/stakeholders.
- Maintains current knowledge of federal, state, and payer regulatory and contract requirements. Stays abreast of policies and regulatory updates and changes and CMS rules and regulations.
- Actively participates in Hospital committees to develop protocols related to evidence-based medicine and supports optimal standards of care.
What You Will Need:
· Graduate from medical school and residency program
· Five years recent clinical practice experience
- Three years of leadership or executive experience
- Current, valid state license as a physician
- Board certified and eligible for membership on the Hospital medical staff
The Denials Management Executive Physician Advisor, educates, advises, and informs members of the Denial Management, Revenue Cycle, Patient Financial Services, Patient Access, Managed Care Departments, and Medical Staff of specific issues, trends or changes related to denial management. This position is an integral part of the regional Denial Management, Documentation Integrity and and Utilization Management Teams, interfacing with the financial and clinical teams and adjudicating cases to full resolution.