Executive Director of Physician Advisor Services

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Benefits

• Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance
• Paid Time Off from Day One
• 403-B Retirement Plan
• 4 Weeks 100% Paid Parental Leave
• Career Development
• Whole Person Well-being Resources
• Mental Health Resources and Support
• Pet Benefits

Schedule

• Full time
• Day shift

Location: 601 E Rollins St, Orlando, Florida, 32803

About the Role

As the physician leader of the physician advisor program, the Executive Director (EDPA) manages, leads, educates, informs, and advises members of the Care Management, Revenue Cycle, and applicable Medical Staff regarding specific regulatory updates, statistical trending, and/or changes related to denial prevention measures for contracted managed care payers. The EDPA is responsible for managing the day-to-day operations of the executive medical directors (physician advisors) in utilization management, assisting Patient Financial Services (PFS) in claims management with denial prevention initiatives, and quality assurance related to inpatient care, outpatient care/observation stays, and referral services.

This position supports the SVP/CMO capacities at the facilities within the Central Florida Division – South Region (CFDSR) by ensuring the delivery of high-quality, efficient healthcare services throughout the continuum of care for the membership served by contracted medical group provider networks. The EDPA is an important contact for clinicians, external providers, contracted health insurance payers, and regulatory agencies. This role serves as a 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.

Responsibilities

• Provide second-level medical necessity reviews that do not meet first-level screening criteria and properly evaluate inpatient utilization patterns within service areas to identify areas of improvement, developing specific strategies and criteria addressing areas of need.
• Collaborate with Senior Medical Officers (and/or CMOs) with contracted managed care payers regarding utilization review management activities and maintain a positive and supportive relationship between the inpatient facilities, health plans, and physicians (hospitalist groups and primary care providers), as well as interdepartmental liaison for ACO activities and program development.
• Review and respond to Complaints & Indicators.
• Work in close coordination with the processes of the Utilization Review Management staff for continual process improvement and reporting.
• Review and make recommendations on appealed provider claims and make determinations for appeals & grievances from members.
• Provide support, share administrative call, and maintain collaborative relations with the other medical directors.
• Participate with the Medical Directorate to review and develop medical guidelines and policies.
• Advise and educate Care Managers regarding clinical issues.
• Act as a physician champion for attending physicians to arrive at the most appropriate inpatient/outpatient utilization determinations.
• Assist in other duties related to utilization review and quality improvement of the network as assigned by the CFO/SEO, SVP/CMO, Vice President Revenue Cycle, and/or Executive Director, Middle Revenue Cycle.
• Review data and trends to identify opportunities for utilization improvement to positively influence practice patterns.
• Conduct regular, ongoing meetings with Care Managers to ensure continuity and efficiency in the inpatient setting.
• Develop clinical care pathways and utilization benchmarking for specialty groups within the CFDSR.
• Manage specialty-specific quality screens and utilization outliers.
• Collaborate and develop relationships with payers and community health resources.
• Actively contribute to efforts to monitor and reduce unnecessary length of stay.
• Participate in the review of long-stay patients, in conjunction with the Director of Utilization Review Management or Executive Director, Middle Revenue Cycle, to facilitate the use of the most appropriate level of care.
• Provide education and serve as a resource to Medical Staff colleagues regarding best practices, Care Management structure and functions, and uses of clinical guidelines.
• Develop and facilitate productive internal/external relationships with all physicians and constituents of Care Management.
• Act as a liaison between contracted managed care/commercial payers related to clinical denials.
• Consult with providers, particularly when difficult issues arise, and have critical conversations concerning resource utilization and medical necessity.
• Work with the clinical documentation improvement team to capture the appropriate ICD-10 codes to ensure documentation reflects the clinical complexity for services rendered.
• Manage how peer-to-peer reviews are conducted with commercial payer medical directors for cases that have been denied.

Compliance/Regulatory Responsibilities

• Educate, consult, and advise members of the Medical Staff on regulatory updates and changes related to Care Management.
• Serve as chair of the Utilization Management (UM) Committee by ensuring the committee is actively reviewing and acting upon trends identified through data.
• Provide trend data of denials to assist in improving payer or care delivery behavior.

Financial Responsibilities

• Aid in supporting Length of Stay (LOS) and quality goals.
• Review concurrent payer denials and intervene with attending and/or consulting physicians and managed care medical directors, as needed, for reconsideration and denial avoidance.

Strategic Planning Responsibilities

• Provide input on developing plans for physician education to meet identified needs and provide information to members of the Medical Staff and clinical departments on Care Management guidelines and protocols.

Performance Improvement Responsibilities

• Provide teaching and guidance to key associates and physicians regarding the impact of responsible stewardship of resources and attainment of important outcomes for each patient and family.
• Manage the efficiency of inpatient care delivered in the organization and collaborate with all levels of the managed care team, utilization review management, hospital executive team including the Chief Medical Officers, and leadership of medical and nursing staff.
• Serve as a liaison between the AHS Managed Care Operations, Care Management, Revenue Cycle, Utilization Review departments, Medical Staff, and the Chief Medical Officers for matters related to physician practice and behaviors as they affect cost, quality, documentation, and patient outcomes.

Community Relations Responsibilities

• Develop and foster relationships with community post-acute care partners to ensure effective communication on patient’s continuum of care practices resulting in optimum patient outcomes.

Requirements

• 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.
• Effective computer skills, particularly Microsoft Office Outlook, Word, Excel, PowerPoint.
• 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.
• Ability to provide expert medical advice.
• Successful history as a practicing physician.
• Strong ability to build and sustain relationships in the medical community and a corporate environment.
• Health plan experience in operations.
• Experience in a physician group model.

Qualifications

• Graduate from medical school and residency program.
• Master’s degree in Business or Healthcare Administration (Preferred).
• Ten (10) years recent clinical practice experience.
• Seven (7) years of leadership experience.
• Understanding of Hospital Care Management, including Utilization Management.
• Two years or greater experience as a Physician Advisor role.
• Previous experience as a Chief Medical Officer (CMO) or Chief Quality Officer (CQO) (Preferred).
• Current, valid State of Florida license as a physician.
• Board certified and eligible for membership on the Hospital medical staff.
• Certified Coding Specialist (CCS) (Preferred).

Pay

Pay Range: $0.00 - $2,080,000.00