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About the Role
The Physician Advisor optimizes efficient management of resources, ensuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities. In this role, you will provide assessment and determination of medical necessity in case evaluation and utilization management. The Physician Advisor collaborates with a multidisciplinary team to implement methods and develop care management protocols that optimize the use of BlueCross BlueShield of South Carolina services for all patients while ensuring quality care is provided.
Responsibilities
- Communicates with hospital physicians, care coordination and utilization management (UM) staff to champion best practices for evidence-based care and its documentation.
- Provides guidance on physician practice patterns, over- and under-utilization of resources, medical necessity, documentation best practices, level of care progression, denial management, and compliance with governmental regulations.
- Performs UM review functions including pre-admission reviews, continues stay reviews, procedure precertifications, post-service reviews, emergency room visit reviews, and individual case management needs.
- Responds to requests for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management department in a timely fashion.
- Keeps abreast of current CMS and MCG evidence-based guidelines to enable UM decisions.
- Maintains compliance with legal, regulatory and accreditation requirements and payor partner policies.
- Uses, protects and discloses patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
- Serves as medical resource for quality improvement.
- Functions as liaison to the medical community.
- Acts as resource for providers/internal staff on medical policies.
- Educates providers on issues concerning medical policies, utilization specifications, and coding/medical necessity issues.
- Conducts research into new/controversial medical procedures/technology as assigned to propose possible policy, coverage criteria, utilization specifications and coding recommendations.
- Participates in medical review policy/quality programs and inter-reviewer reliability studies.
Requirements
- Medical Doctor (MD) or Osteopathic Doctor (DO) with current license to practice.
- If Physician Advisor - Doctor of Psychiatry (MD) with current active medical license, without restriction.
- 8 years broad clinical experience to include knowledge of utilization and medical review.
- Experience may include paid training.
- Demonstrated ability to direct multiple strategic projects.
- Excellent verbal and written communication skills.
- Excellent judgment, organizational, customer service, presentation skills.
- Excellent analytical or critical thinking skills.
- Knowledge of strategic concepts.
- Ability to persuade, negotiate, or influence others.
- Microsoft Office proficiency.
- Active, unrestricted medical license from the United States and in the state of hire.
- Current board certification in a recognized specialty.
Skills
- Utilization review
- Medical review
- Prior authorization review
- Medical data analysis
- Analytical capability to interpret statistical information
- Medical oversight of quality improvement activities
- Quality committees
- NCQA
- Population based disease management
- Public health initiatives
- Medical management
- Managed care
- Medicare programs
Location
- United States
Work Type
- Full-time
- Remote
Experience Level
- 8 years broad clinical experience
- 2 years medical data analysis
Education Level
- Medical Doctor (MD)
- Osteopathic Doctor (DO)
- Doctor of Psychiatry (MD)
Salary/Compensations
- $176,132.00 - $355,017.00
Benefits
- Subsidized health plans, dental and vision coverage
- 401k retirement savings plan with company match
- Life Insurance
- Paid Time Off (PTO)
- On-site cafeterias and fitness centers in major locations
- Education Assistance
- Service Recognition
- National discounts to movies, theaters, zoos, theme parks and more
About the Company
- Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community.
- We are the largest insurance company in South Carolina … and much more.
- We are one of the nation's leading administrators of government contracts.
- We operate one of the most sophisticated data processing centers in the Southeast.
- We also have a diverse family of subsidiary companies, allowing us to build on various business strengths.
- We deliver outstanding service to our customers.
Equal Opportunity
- BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status.
- As a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans.
- It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
- We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
- We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision.
- We are an Equal Opportunity Employer.