The On-Site Physician Advisor (OSPA) conducts timely and compliant medical necessity reviews and assists with denials management (facilitating and completing peer to peers, writing appeal letters) in support of the centralized system Utilization Review (UR) process for Sentara hospital facilities. The Physician Advisor serves an important role in ensuring compliant hospital status/billing for hospital patients and strengthening relationships between Clinical Revenue Cycle, UR, hospital leadership, medical staff, and hospital ICM. The Physician Advisor interfaces directly with the medical staff, providing concurrent communication and education to attending physicians (and their APCs) regarding recommended changes in hospital status, pertinent regulatory requirements and guidance impacting the determination, as well as documentation integrity to support medical necessity of services being delivered.

As this role’s duties include significant interpersonal and relational aspects in addition to regulatory training and licensing requirements, an active and unrestricted Virginia medical license and board-certified status at the time of hire are required, as well as superb interpersonal and communication skills. Due to the collaborative and highly relational nature of this role, on-site (in person) presence is integral. Coverage at additional sites may be required, including occasional in-person responsibilities. The position reports to the Director of Regional Physician Advisors to Clinical Revenue Cycle.

– Perform timely and compliant medical necessity reviews, providing clear documentation of the pertinent details of the case to satisfy regulatory requirements and directly communicating any necessary
– Facilitate denials management through review of selected cases, conducting peer to peer discussion with third party payers as appropriate, and assisting with appeals letters
– Work closely with hospital leadership, medical staff, and hospital ICM leaders to support system CPIs and initiatives
– Attend and participate in Hospital UM committees at designated sites
– Complete training and continuing education as deemed necessary
– Attend and participate in educational presentations to medical staff, administration, leadership and peers
– Additional functions as deemed appropriate and warranted

Minimum Requirements:

– Completion of Medical doctorate or Doctor of Osteopathy degree from an accredited medical school
– Completion of an accredited residency training program
– Minimum of 3 years of clinical experience, hospital clinical experience strongly preferred
– Active and unrestricted state Virginia medical license
– Board certification in specialty required at time of hire
– Possess or acquire a working knowledge of CMS regulatory guidance and requirements as they pertain to UR and site of service decisions
– Possess a working knowledge of clinical documentation integrity, hospital billing and coding processes and guidelines, case mix index, and DRG assignments
– Familiarity with standard published leveling criteria such as MCG/Interqual and ability to apply professional judgment and patient specific variables as may be necessary or justifiable
– Familiarity with (Hospital) organization and case management operations
– Excellent customer service and interpersonal skills.
– Able to effectively present information, both formal and informal
– Superb written and verbal communications skills
– Ability to set and manage priorities
– Demonstrate flexibility, teamwork, and a collaborative leadership style
– Strong technical/computer skills and working knowledge of the system’s EMR