APPENDIX M

PHYSICIAN ADVISOR
Job Description
 JOB TITLE: Physician Advisor
 DEPARTMENT: Case Management
JOB SUMMARY: The physician advisor is responsible for reviewing all concurrent and retrospective denials brought to his attention by the case management staff. The physician advisor will review the case for medical necessity against established criteria and make a determination as to whether the case is appealable. If the case is appealable, the physician advisor will pursue the case by utilizing the concurrent appeal process or the retrospective appeal process as appropriate.
REPORTS TO: Director of Case Management
 SUPERVISES: No one
RESPONSIBILITIES:
  1. All potential or actual denials (whether concurrent or retrospective) are referred by the case managers except for the following:
    a. Cases denied because of lack of precertification
    b. Cases denied that are paid based on diagnostic-related groups (DRGs)
    c. Cases that are "technical" denials
    d. Potential denials
  2. All concurrent denials are attended to immediately upon, or as soon as possible after, referral.
  3. All retrospective denials are prioritized for completion based on the date by which the appeal must be submitted to the payer.
  4. A data worksheet is completed for every case reviewed. The worksheet includes patient demographic information and pertinent clinical information. Standardized clinical criteria (e.g., InterQual or Milliman & Robertson) are applied to refute the payer denial.
  5. All cases meeting standardized clinical criteria are appealed.
  6. Those concurrent cases felt to be medically justified, despite lacking adherence to standardized criteria, will be pursued using the concurrent appeal process.
  7. Those retrospective cases felt to be medically justi-fied, despite lacking adherence to standardized criteria, will be pursued by preparing a clinical justification appeal letter to be included in the appeal packet sent to the payer.
  8. For concurrent cases not fitting into one of these criteria, the case is pursued with the attending physician of record to:
    a. Obtain clinical information about the patient that may not be apparent from a review of the medical record but that may be sufficient to justify an acute care stay
    b. Educate the physician on the criteria used to determine the necessity of an acute care stay
    c. Ensure that the patient is in the most appropriate setting or the level of care needed
  9. For retrospective cases not fitting into one of these criteria, the case is appealed without a clinical justification appeal letter from the physician advisor.
  10. Will prepare a monthly activity report of appealed cases and the outcomes of those appeals. The format and content of the report will be determined by the director of case management.
  11. Will participate in physician education programs regarding reimbursement, clinical criteria, and documentation as needed.
  12. Will serve as a liaison between the physician staff and the case management staff.
  13. Will maintain positive working relationships with the medical directors of the third parties.
EXPERIENCE: Previous utilization management experience preferred. A working knowledge of InterQual and Milliman & Robertson criteria essential.
EDUCATION:
  1. Licensed medical doctor
  2. Utilization certification preferred
SKILLS: Excellent clinical and administrative skills and judgment. Strong interpersonal and communication skills. Ability to effectively work with other disciplines and departments and outside agencies.