The Regional Physician Advisor supports the Clinical Revenue Cycle’s Utilization Review and Denials/Appeals processes to determine and secure appropriate level of care assignments to ensure compliant billing, assist with denials management, support documentation integrity as it pertains to accurate coding capture. The Regional Physician Advisor interfaces with hospital and medical staff leadership, facilitating communication between Revenue Cycle leadership and processes and the hospital facilities and championing processes and initiatives. The Regional Physician Advisor assists with both formal and informal education of medical staff at Sentara hospital facilities. This role is responsible for supporting and meeting the Clinical Revenue Cycle functions organizational goals and objectives for assuring the effective, efficient utilization of health care services.

Due to regulatory requirements, this role requires an active and unrestricted Virginia medical license, thorough understanding of the Medicare regulatory requirements as they relate to hospital UR activities and medical necessity criteria/tools, high level of proficiency working within Epic (EMR), and a working knowledge of clinical documentation integrity and hospital coding/billing practices. The nature of this role is collaborative and highly relational, and therefore requires significant on-site (in person) presence to facilitate development of relationships, communication and education. Superlative interpersonal and communication skills as well as superb analytical skills are integral to the success of the role. Coverage at additional sites may be required, including occasional in-person responsibilities at sites within a 25 mile radius of assigned primary sites. The position reports to the Director of Regional Physician Advisors.

Principal Duties and Responsibilities:
• Perform timely and compliant third level medical necessity site of service/status reviews, providing clear documentation of the pertinent details of the case to satisfy regulatory requirements
• Facilitate denials management through review of selected cases, conducting peer to peer discussion with third party payers as appropriate, and assisting with appeals letters as appropriate
• Work closely with hospital leadership, medical staff, and hospital ICM leaders to support system CPIs and initiatives
• Actively participate in Hospital UM committees at designated sites
• Supervise Physician Advisor staff
• Recruit and mentor Physician Advisors
• Participate in training and continuing education for the Physician Advisor program
• Present educational topics to medical staff, administration, leadership and peers
• Complete evaluations of staff Physician Advisor work product
• Attend continuing education pertaining to utilization and quality management
• 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 5 years of clinical experience, hospital clinical experience strongly preferred
• Minimum of 2 years of physician advisory experience strongly preferred
• Active and unrestricted state Virginia medical license
• Board certification in specialty required at time of hire
• Posess or acquire a thorough understanding 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
• Strong organizational and analytic skills, and 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
• Ability to provide a consistent on-site presence at assigned sites