Physician Advisor / Medical Director - Utilization Management - AdventHealth West Florida Division at AdventHealth

Date Posted: 7/15/2021

Job Snapshot

  • Job Schedule
  • Location:
    Tampa, FL
  • Date Posted:
  • Job ID:
  • Job Family
    Patient Financial Services
  • Shift
    1 - Day

Job Description


Physician Advisor / Medical Director at AdventHealth West Florida Division -Tampa, FL

Location Address: 14055 Riveredge Dr, Tampa, FL  33637

Top Reasons to Work at AdventHealth Tampa

  • AdventHealth Pepin Heart Institute, known across the country for its advances in cardiovascular disease prevention, diagnosis, treatment and research.
  • Surgical Pioneers – the first in Tampa with the latest robotics in spine surgery
  • Building a brand new, six story surgical and patient care tower which will ensure state of the art medical and surgical car for generations to come
  • Awarded the Get With The Guidelines – Stroke GOLD Quality Achievement Award from the American Heart Association/American Stroke Association and have been recognized as a recipient of their Target: Stroke Honor Roll for our expertise in stroke care. We have also received certification by The Joint Commission in collaboration with the American Stroke Association as a Primary Stroke Center.

Work Hours/Shift:

Full Time, Salaried.

You Will Be Responsible For:

  • Provides clinical support/validation for both Utilization Management and Care Management teams
  • Provides education and serves as a resource to Medical Staff colleagues regarding best practices, Utilization Management and Care Management structures, and functions and use of clinical guidelines
  • Develops and facilitates productive internal/external relationships with all physicians and constituents of Utilization Management and Care Management
  • Provides suggested approaches to clarifying clinical questions when Utilization Management and Care Management staff interact with physicians, nurses, or other health professionals
  • Maintains a positive and supportive relationship between the inpatient facilities, payors and physicians (hospitalist groups and primary care providers), and acts as the interdepartmental liaison for ACO activities and program development
  • Provides guidance to clinical questions from Utilization Management staff involved in authorizations, concurrent review, and denials
  • Assists with interpretation of specific application of medical necessity criteria
  • Responsible for reviewing and authorizing inpatient (IP) days – performs secondary review escalations
  • Evaluates IP utilization patterns - Overutilization of specific resources/testing as it relates to a specific service area
  • Assists in formulation of reasonable clinical arguments to address any questions regarding level of care
  • Coordinates and supports both concurrent (Utilization Management) and retrospective (Central Denial Service) clinical denial management by reviewing and making recommendations on appealed provider claims and makes determinations for appeals and grievances from patients; assists in drafting and submitting clinical denial appeals, as needed
  • Develops Medical Director relationships with payors to have open communication and consistently meets with these individuals to have mutually beneficial conversations to improve denials, decrease days in A/R and increase clean claims rate
  • Performs peer-to-peer discussions with payer Medical Directors and/or discusses cases with payer representatives to facilitate claim resolution and build payer relationships
  • Collaborates with Chief Medical Officers and acts as a liaison between contracted Managed Care/Commercial payors related to managed care denials, Care Management and the Hospital’s Medical Staff
  • Works in close coordination with the processes of the Utilization Management staff for continual process improvement and reporting
  • Reviews denials data and trends and works with Managed Care contracting team and patient financial services to identify opportunities to address retrospective denials through the contracting process
  • Reviews key performance indicators and progress to targets; reviews data and trends to identify opportunities for utilization improvement to positively influence practice patterns and address avoidable delays
  • Serves as a resource for the Utilization Management (UM) Committee and shares observations, information and trends identified through data and case reviews
  • Conducts regular, ongoing meetings with Care Management to ensure continuity and efficiency in the inpatient setting, as well as, educate on common problematic clinical issues
  • Provides guidance to clinical questions from Care Management staff regarding appropriateness of placement in terms of patient’s clinical status/care needs
  • Supports long stay meetings to effectively manage length of stay. Generates clinically sound alternative ideas and approaches to complex and/or long stay patients
  • Provides multidisciplinary, big-picture approaches that coordinate clinical, psychosocial, payor, financial and other needs
  • Promotes communication of expected discharge date with multidisciplinary team, patients and families
  • Collaborates with Clinical Documentation Integrity leadership and meets at least quarterly to assist in the identification of clinical documentation improvement opportunities
  • Collaborates with Quality and Patient Safety leadership and meets at least quarterly to share opportunities identified to enhance patient outcomes
  • Assists in the review and revision processes of current clinical care pathways while providing insight and input on future pathway development. Escalates concerns to Regional/Divisional and Facility Chief Medical Officers, as appropriate
  • Serves as an active member of the Regional/Divisional Medical Staff Committees and other clinical and/or finance related groups as determined by the Divisional Chief Medical Officer in order to build trusting relationships and share observations and provider improvement opportunities
  • Collaborates with Medical Director(s) to review and provide insight regarding medical guidelines and policies
  • Assists in other duties related to utilization management, clinical documentation and quality improvement of the network as assigned by the Divisional Chief Medical Officer
  • Supports compliance with all State and Federal regulations

What You Will Need:

  • Strong organization skills with attention to detail
  • Excellent analytical and problem-solving skills
  • Effective oral and written communication skills, with the ability to articulate complex information in understandable terms to all levels of staff
  • Understanding of Microsoft Office Products and other appropriate software platforms
  • Ability to work in a matrix-management environment to achieve organizational goals
  • Ability to translate ethical and legal requirements into practical and sustainable policies, balancing the needs of the business and the interest of patients and member physicians alike
  • Demonstrated ability to provide expert medical advice
  • Successful history as a practicing physician
  • Demonstrated ability to build and sustain relationships in the medical community and a corporate environment
  • Payor experience in operations
  • Experience in a physician group model
  • Direct involvement with supporting the development of a Utilization Management and Care Management departments is preferred
  • Knowledge of change management principles, methodologies, and tools is preferred
  • Graduate of accredited Medical School required
  • Bachelor of Science required
  • Minimum of 5 years of experience in hospital medicine in acute care setting required
  • Master’s degree in Business or Healthcare Administration preferred
  • Two (2) years or greater experience as a Physician Advisor preferred
  • Prior experience with third party payors preferred 
  • Current and valid license as a physician required
  • Board certified and eligible for membership on the Hospital medical staff required
  • Healthcare Quality and Management Certification (HQCM) preferred

Job Summary:

The Physician Advisor provides primary support for Utilization Management (UM) and secondary support for Care Management (CM) departments and serves as a liaison between UM and CM teams and medical staff, as well as, the medical liaison for payor escalations. The Physician Advisor is responsible for educating, informing and advising members of the Utilization Management, Care Management, Managed Care and Revenue Cycle departments and applicable medical staff, as well as collaborating with other disciplines to assist in the improvement of clinical documentation, patient safety, and quality outcomes.

Through primary support of Utilization Management, the Physician Advisor is responsible for providing clinical review of utilization, claims management, and quality assurance related to inpatient care, outpatient care/observation stays and referral services. The Physician Advisor is an important contact for clinicians, external providers, contracted health insurance payors, and regulatory agencies. This individual also serves as the subject matter expert, providing clinical expertise and business direction in support of medical management programs, promoting the delivery of high quality, patient focused and cost-effective medical care.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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