Medical Director of Revenue Integrity (Lead Physician Advisor)

Job Requirements

Role Summary

The Medical Director of Revenue integrity (Physician Advisor) is a key member of the healthcare organization's leadership team and is charged with meeting the organization's goals and objectives for assuring the effective, efficient utilization of health care services.

The Physician Advisor is a physician serving the hospital through teaching, consulting, and advising the care management and utilization review departments, healthcare data team and the hospital leadership.

The Physician Advisor shall develop expertise on matters regarding physician practice patterns, over and underutilization of resources, medical necessity, levels of care, care progression, denial management, compliance with governmental and private payer regulations, appropriate physician coding and documentation requirements.

Core 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 discussion with Payor Medical Directors when requested.
• Provides necessary clinical education to UR Case Managers regarding clinical criteria and appropriate us of screening tools.

• Educates individual hospital staff physicians about current ICD and DRG coding guidelines.
• Collaborates with CDI and coding team to develop complaint query practices, optimize review process, and provide necessary clinical support in DRG assignment as needed.

• 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 contract process and physician contract process for quality measures.
• Participates in efforts to reduce inappropriate readmissions.
• Collaborates with Healthcare Data team to identify areas or processes contributing to excessive cost of care.

• Optimize service line revenues through proactive approaches and strategies.
• Participates in hospital committees to support and develop protocols related to evidence-based medicine and support optimal standards of care.

• Collaborates with the Chief Financial Officer to identify short term and long-term goals.

The above statements are intended to describe the general nature and level of work performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of personnel so classified and employees may be required to perform other duties as assigned.

Work Experience

Knowledge, Skills, and Abilities

• Ability to drive strategic direction
• Knowledge of revenue cycle, clinical documentation, and payor relationships
• Ability to educate providers and stakeholders in a timely and effective manner
• 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 towards goals
• Strong knowledge of Medicare Two Midnight rules
• Ability to interact respectfully with diverse cultural and socio-economic populations

Minimum Requirements

• Hold and maintain or 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 healthcare business, revenue cycle, utilization management, coding, clinical documentation improvement principals, or government/ regulatory value programs related

Experience

• Current American College of Physician Advisors (ACPA) membership
• 6 months (one of the following must be obtained within six (6) months of start date):
• Current American Board of Quality Assurance and Utilization Review Physicians (ABQAURP)certificate within six (6) months of start date
• Current American College of Physician Advisors Certification (ACPA-C) from the American College of Physician Advisors (ACPA) within six (6) months of start date

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

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