Physician Advisor, Quality Utilization Management

Physician Advisor, Quality Utilization Management

The Physician Advisor, Utilization Management (UM), provides clinical and management guidance to enhance process improvement and resource management at the hospital level. Reporting to the Regional Medical Director, the Physician Advisor collaborates with CCC/DP & UR teams, physicians, and hospital leadership to improve medical quality, service, and financial outcomes. This role includes educating staff, leading UM committees, and supporting care coordinators, Emergency Department, and hospital throughput.

Key Responsibilities

• Clinical & Management Guidance
• Provide expertise in UM, advocating for the hospital system goals in process improvement and resource management.
• Support care coordination nurses, UR nurses, attending physicians, and administrative leadership in UM functions.

Communication & Education

• Engage with physicians and surgeons to promote the proper utilization of resources.
• Serve as a physician leader and educator on clinical documentation, medical necessity, denial reduction, throughput, and discharge planning.
• Provide documentation tips to the team during daily SWAT calls.

Operational Oversight

• Attend daily rounds on the floors and/or SWAT, addressing delays in care and unnecessary testing/treatments.
•  Lead the hospital’s Utilization Review Committee, identifying trends and implementing improvement plans.
• Use measurable standards to monitor and evaluate the quality and cost-effectiveness of patient care.
• Facilitate communication between managed care/commercial payors and providers regarding benefit coverage, utilization review, and quality assurance.

Compliance & Best Practices

• Ensure compliance with URAC standards, CMS policy, and other regulatory requirements.
• Promote evidence-based treatment plans and adherence to established UPMC care protocols.

Process Improvement

• Identify, address, and remove avoidable delays in care, collaborating with clinical teams to streamline processes.
• Implement system-wide care plans, order sets, and discharge plans to promote efficient care delivery and achieve GMLOS goals.

Documentation & Appeals

• Maintain clear and concise documentation of all UM activities in UPMC’s Care Management information system.
• Conduct or assist in concurrent appeals for denied or downgraded coverage determinations by payors.
• Analyze payer trends and denial patterns, developing strategies for improvement with the Regional Medical Directors.

Collaboration & Strategy Development

• Meet regularly with the Regional Medical Director to develop and implement regional strategies for UM improvement.
• Collaborate on payer strategies to manage denials and address trends in payer behavior.

Peer Collaboration & Support

• Assist with the Peer-to-Peer Process.
• Collaborate with hospital administration and ancillary leadership to improve operational efficiencies impacting care delivery.