Medical Director of Revenue Integrity (Lead Physician Advisor)

About the Role

The Medical Director of Revenue Integrity (Physician Advisor) is a key member of the healthcare organization's leadership team, responsible for meeting the organization's goals and objectives for assuring the effective, efficient utilization of healthcare services. This role involves teaching, consulting, and advising care management, utilization review departments, the healthcare data team, and hospital leadership.

The Physician Advisor develops expertise in physician practice patterns, resource utilization, medical necessity, levels of care, care progression, denial management, compliance with regulations, and appropriate physician coding and documentation requirements.

Responsibilities

• Provides functional leadership for the revenue integrity team, including CDI, Coding, and Utilization Review (UR).
• Oversees optimization of revenue integrity systems and operations.
• Chairs the Utilization Management (UM) Committee.
• Supports development, adoption, and utilization of value-based care initiatives.
• Reviews patient medical records identified by case managers or as requested by the healthcare team to perform quality and utilization oversight.
• Performs medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews.
• Provides regular feedback to physicians and other stakeholders regarding level of care, length of stay, and potential quality issues.
• Conducts Peer-to-Peer discussions with Payor Medical Directors when requested.
• Provides clinical education to UR Case Managers regarding clinical criteria and appropriate use of screening tools.
• Educates hospital staff physicians about current ICD and DRG coding guidelines.
• Collaborates with CDI and coding teams to develop compliant query practices, optimize review processes, and provide clinical support in DRG assignment.
• Provides direct clinical support to CDI manager and RAC auditor for DRG level of care denials.
• Conducts physician education sessions to share data, trends, practice patterns, and other relevant information.
• Documents session outcomes and relevant information.
• Reports practice pattern trends and opportunities to service line or department-specific meetings at the request of the CMO or hospital leadership.
• Supports payor and physician contract processes for quality measures.
• Participates in efforts to reduce inappropriate readmissions.
• Collaborates with the Healthcare Data team to identify areas contributing to excessive cost of care.
• Optimizes service line revenues through proactive approaches and strategies.
• Participates in hospital committees to support and develop protocols related to evidence-based medicine and optimal standards of care.
• Collaborates with the Chief Financial Officer to identify short-term and long-term goals.

Requirements

• Hold and maintain or be able to obtain an unrestricted medical license in the state of Wyoming.
• Ten (10) or more years of healthcare and/or patient care experience.
• Two (2) or more years of experience in healthcare business, revenue cycle, utilization management, coding, clinical documentation improvement principles, or government/regulatory value programs.
• Current American College of Physician Advisors (ACPA) membership.
• Within six (6) months of start date, obtain one of the following:
  • Current American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) certificate, or
  • Current American College of Physician Advisors Certification (ACPA-C) from the American College of Physician Advisors (ACPA).

Preferred Qualifications

• Certified Medical Director (CMD).
• Medical billing, coding, or abstracting experience.
• Internal Medicine experience with a background in Hospital Medicine.
• InterQual experience.
• MCG experience.

Skills

• Ability to drive strategic direction.
• Knowledge of revenue cycle, clinical documentation, and payor relationships.
• Ability to educate providers and stakeholders effectively.
• Process improvement, quality improvement, planning, and decision-making skills.
• Knowledge of regulatory requirements.
• Advanced knowledge of patient safety principles, risk management, and strategies to minimize harm.
• Ability to build rapport with stakeholders to obtain buy-in and collaboration.
• Strong knowledge of Medicare Two Midnight rules.
• Ability to interact respectfully with diverse cultural and socio-economic populations.