Advanced Practice Provider Advisor

GENERAL SUMMARY:

Collaborates with utilization review, Bryan Medical Center (BMC) providers, billing, and physician advisors to ensure clinical information given to insurance companies is complete and appropriate. Performs clinical case status reviews and provides recommendations that focus on establishing the appropriate admission status according to guidelines set forth by Centers for Medicare and Medicaid Services (CMS). Assists Utilization Management Team and physician advisors to manage complex and unforeseen challenges such as complex regulatory updates and downstream policy changes set forth by Medicare and private payor organizations resulting in financial difficulties. Provides measures to improve compliance and ensures appropriate payment for the care delivered. Analyzes appeal and denial claims as well as quality and performance improvement activities. Provides education about denial trends, clinical information improvement strategies, and insurance guideline updates to utilization review and providers.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, and beliefs and consistently demonstrates our core values.
2. *Performs peer-to peer conversations with Medicare Advantage, Medicaid health plans, and commercial payers per regulatory and contractual agreements.
3. Maintains the denial queues.
4. *Conducts a primary medical necessity review on cases that are in observation status.
5. Reviews Code 44 Cases.
6. *Maintains APP Advisor work queue providing feedback on inpatient and observation cases.
7. *Conducts first and second level medical necessity reviews for all patient cases that do not meet first level inpatient criteria.
8. *Completes the Medicare work queue by evaluating all short stay Medicare FSS cases for self-audit and billing of Part A services.
9. Assists Utilization Management (UM) manager with UM education.
10. *Provides feedback to attendings and consulting physicians regarding clinical status decisions and documentation.
11. Communicates with physicians regarding escalated UM issues.
12. *Communicates with Senior Leadership and the UM Committee on issues that are not resolved at the APP Advisor to physician level.
13. *Provides education for BMC physicians and APP's at educational meetings.
14. Uses appropriate criteria to assist UM RNs with UM case review submissions.
15. Assists UM manager with medical necessity for Clinical Review meetings with the payers and attend payer representative meetings as directed.
16. *Provides metric and data information to UM manager and senior leadership on performance of UM.
17. Assists UM manager in coordination and facilitation of the Utilization Management Committee meeting each quarter.
18. Provides constructive feedback on queries, reviews, and performance in conjunction with the UM manager.
19. Participates in continuing education through RAC Relief google groups, BMC consulting initiatives and other APP professional societies.
20. Remains current on all regulatory changes for CMS.
21. Reviews and distributes new Inpatient Only Procedures Lists.
22. Reviews and works collaboratively with the UM manager on UM process/policies/improvements.
23. *Reviews and analyzes third-party vendor data reporting on ideas for improvement and cost-savings.
24. *Researches and compiles underlying root causes of denials and strategies to prevent denials and improve clinical documentation.
25. *Tracks clinical documentation improvement metrics to monitor reimbursement and emerging trends.
26. *Collaborates with senior leadership, CDI and PFS on creating order sets / smart phrases to improve documentation for providers that align with CMS regulations.
27. *Educates physicians and staff concerning clinical documentation improvement by increasing queries, responses, and agreement rates.
28. Available to receive emergent phone calls on weekends, holidays and after business hours.
29. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
30. Participates in meetings, committees and department projects as assigned.
31. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk "*." Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES:

1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient's growth and developmental needs, annual skill competency verification and mandatory education and competencies.
2. Knowledge of and familiarity with current medical literature, healthcare reimbursement issues (i.e., medical necessity, levels of care, coding), MCG/Inter Qual screening criteria, Medicare/Medicaid compliance, and medical staff structure, policies, and procedures.
3. Knowledge of computer hardware equipment and software applications relevant to work functions.
4. Demonstrated ability to deliver high quality, cost-effective, efficient patient care services.
5. Ability to develop and maintain relationships.
6. Ability to build rapport with medical staff, third-party physician advisors and hospital leadership.
7. Ability to task switch and prioritize assignments based on BMC and payor deadlines.
8. Ability to communicate effectively both verbally and in writing.
9. Ability to perform crucial conversations with desired outcomes.
10. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff.
11. Ability to problem solve and engage independent critical thinking skills.
12. Ability to maintain confidentiality relevant to sensitive information.
13. Ability to prioritize work demands and work with minimal supervision.
14. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

Graduation from an accredited Physician's Assistant program required. Current licensure in the State of Nebraska as a Physician Assistant required. Minimum of three (3) years of clinical Advanced Practice Provider experience and three (3) years of Utilization Management experience or equivalent required.

OR

Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required. Master of Science degree in Nursing with current Advanced Practice Registered Nurse licensure from the State of Nebraska required. Minimum of three (3) years of clinical Advanced Practice Provider experience and three (3) years of Utilization Management experience or equivalent required.

OTHER CREDENTIALS/CERTIFICATION:

Certification with the U.S. Drug Enforcement Administration for prescriptive authority required.

Basic Life Support (CPR) certification is required. Bryan Health recognizes the American Heart Association (for healthcare professionals), the American Red Cross (for healthcare professionals), and the Military Training Network.

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) - Characterized as sedentary work requiring exertion of up to ten pounds of force occasionally and/or negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. Prolonged periods of standing, walking, and/or moving while making rounds within the Medical Center are typical.