Summary:

The Physician Liaison (Physician Advisor) acts as liaison between medical staff, clinical management, and third party payors to promote the efficient utilization of resources and to select the appropriate levels of medical care within the WMC Health Network. The position will perform clinical reviews as mandated by regulatory requirements and the organization's Utilization Review Plan. The Physician Advisor may serve as a member of Utilization Review Committees at multiple facilities. Will provide peer education and serve as a consultant for physicians and staff members. They will also participate in process/performance improvement discussions to improve clinical outcomes, compliance with regulatory requirements, and address reimbursement issues including appeals.

RESPONSIBILITIES:

• Reviews imaging cases when clinical determinations cannot be made by initial clinical review.
• Discusses determinations with requesting physicians or ordering providers when available within the regulatory timeframe of the request by telephone or fax.
• Provides clinical rational for standard and expedited appeals.
• Participate in peer to peer review with payors and/or complete appeals as required to overturn denials
• Provides assistance to initial clinical reviewers as needed to discuss cases and problems.
• Participates in daily review of aggregate denials/appeals with the Medical Director, peer, or the Clinical Review Supervisor.
• Provides continuous education to physicians as needed on payor policies and workflows
• Utilizes medical review guidelines and parameters to assure consistency in the review process to reflect appropriate utilization and compliance with various organizations
• Documents all communications with provider and records in a timely and accurate manner.
• Functions as a resource for initial clinical reviewers.
• Performs other duties as assigned.

QUALIFICATIONS / REQUIREMENTS:

Experience:

• 3-5 years of clinical hospital experience preferred
• Knowledge of CMS, Interqual or MCG regulations preferred
• Minimum of 5 years of preferred experience in a clinical setting with patient care
• Certified by National Commission on Certification of Physician Assistants (NCCPA)

Education:

• Physician Assistant with appropriate certifications

• Current unrestricted PA certification

Other:

Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.

About Us:

Good Samaritan Hospital

Good Samaritan Hospital in Suffern, NY, is a 286-bed hospital providing emergency, medical, surgical, obstetrical/gynecological and acute-care services to residents of Rockland and southern Orange counties in New York; and northern Bergen County, NJ. The hospital is home to a recognized cardiovascular program, comprehensive cancer-treatment services, the area's leading Wound and Hyperbaric Institute and outstanding maternal/child services that includes a Children's Diagnostic Center. Good Samaritan Hospital also provides social, psychiatric and substance-abuse services and its certified home-care agency supports residents of the Hudson Valley and beyond.