The Physician Advisor role assists institutions to realize improved financial,
quality and patient flow measures that are essential
to achieving the goals of value-based care. The ultimate goal of the Physician Advisor: advocacy
for patients and families, as well as fellow practitioners.
PA Standards and Scope Brochure
Standards of Practice
The Physician Advisor Standards of Practice outline
the requirements and competency to function in
this role.
Professionalism
The Physician Advisor holds an active medical license
and participates in ongoing continuing medical
education as required by their healthcare delivery
entity to remain up to date on practice, procedures
and treatment protocols. Expectations regarding
professional conduct include confidentiality,
interprofessional collegiality, ethical behavior and a
commitment to ensuring high quality, appropriate,
safe and compassionate care for all. The Physician
Advisor manages conflict of interest issues and
recuses self, as needed.
Leadership
The Physician Advisor leads by example, is an
influencer and acts as a change agent to achieve
programmatic goals. The Physician Advisor
demonstrates operational effectiveness within the
structure of the organization, and advocates for the
role of the Physician Advisor within the organization
as a catalyst for value-based care initiatives. The
Physician Advisor develops organizational
knowledge, utilizes and leverages strengths and
resources within the organization, and identifies and
addresses local and regional factors which affect
care delivery. The Physician Advisor provides support
for strategic goals and drives behaviors which
achieve meaningful and measurable outcomes. The
Physician Advisor collaborates with case
management leadership.
Advocacy
The Physician Advisor balances advocacy and
support for patients, families, practitioners and
professional staff and the organization they serve.
Accountability
The Physician Advisor represents the medical staff
and medical community standards of practice. The
Physician Advisor demonstrates accountability, which
is exhibited in a variety of ways: supports
performance improvement to drive care
management metrics, remains current on healthcare
and payor regulatory provisions, provides timely
follow up on case prioritization with physicians and
care management leaders, attends utilization review
meetings and represents care management in
hospital-wide initiatives. The Physician Advisor reviews
cases as needed to meet criteria for medical
necessity, quality, and desired outcomes. The
Physician Advisor is responsible for addressing and
escalating as appropriate challenging, high conflict
or outlier case circumstances, and serves as a mentor
for clinical documentation.
Communication
Excellent and timely communication amongst
patients, families, care managers, physicians
and payors is an important component of the
Physician Advisor role. This includes peer-to-peer
discussion and clinical documentation opportunities.
The Physician Advisor demonstrates the ability to
facilitate and de-escalate difficult conversations in
a professional manner.
Collaboration
The Physician Advisor respects and values the
contributions of all disciplines and builds relationships
that foster trust and confidence. The Physician
Advisor demonstrates credibility and problem-solving
skills. The Physician Advisor mediates amongst
different departments, teams, or individuals involved
with the patient’s episode of care.
Regulatory Knowledge
The Physician Advisor aligns and drives performance
improvement opportunities within the medical staff and
care management team to achieve the highest quality
and regulatory compliance. An operational knowledge
of CMS guidelines and a keen understanding of the
payor market and managed care contracts is essential.
Continuum of Care Perspective
The Physician Advisor exhibits an understanding of
value-based care models, including a longitudinal
perspective of the care delivery focused on the right
intervention, at the right time, and in the right care
setting. The Physician Advisor works to align all
stakeholders across the care continuum.
Data Literacy
Essential to the Physician Advisor role is the ability to
identify, interpret, synthesize and apply relevant
quality measures to achieve meaningful outcomes.
The Physician Advisor leverages outcome data to
drive and improve strategic organizational
performance and demonstrates expertise in
optimizing the electronic medical record.
Scope of Services
The Physician Advisor scope of services outlines
general expectations of the role and responsibilities.
Services delivered by Physician Advisors include:
1. Advocate
- Promotes alignment and collaboration with
physicians regarding culture, satisfaction,
engagement and problem solving
- Acts as a liaison to case management, the CMO,
professional staff and hospital administration for
questions or concerns
- Advocates for patient/family-centered care and
health equity
- Partners with medical and professional staff to promote
organizational stewardship of healthcare resources
2. Care Progressions and Transitions
- Concurrently reviews cases to achieve timely
and effective care across the continuum
- Participates in case reviews regarding levels
of care, length of stay, resource utilization and
avoidable delays
- Applies clinical knowledge for appropriate
length of stay
- Supports care management in progressing care
to meet length of stay goals
3. Education
- Demonstrates up-to-date knowledge of
newest technologies, clinical practice guidelines
and treatments
- Promotes and supports patient safety initiatives
- Assists medical and professional staff with
education regarding DRG LOS, denials, clinical
documentation, practice guidelines within the EMR
and any regulatory changes
- Drives performance improvement by sharing
physician specific data regarding LOS, readmissions,
use of hospitalist program, and case denials
- Supports education to minimize clinical variability
throughout the medical staff
- Serves as a resource for CDI and coding specialty
4. Utilization Management
- Ensures compliance with CMS conditions of
participation and managed care contracts
- Drives performance improvement
- Participates in Medicare audit reviews
- Participates in the appeals process
5. Medical Necessity Reviews and Compliance
- Performs clinical reviews on cases referred by
healthcare professionals and ensures quality and
effective patient care is provided
- Advises physicians regarding patient status and
appropriate and necessary documentation
- Supports efficient patient flow and appropriate
patient placement, and effectively coordinates
with stakeholders across the continuum of care
6. Clinical Documentation
- Collaborates with Clinical Documentation team to
ensure timely documentation to support working
DRG, in compliance with ICD-10 requirements
- Follows up with physicians and professional staff
to address documentation deficiencies and to
update on procedural and terminology changes
7. Certification
- Certification validates a physician’s knowledge,
competency, and skills. Physicians holding a Care
Management Physician Certification (CMPC)
credential have demonstrated that they are qualified
to provide Physician Leadership in Care Management
services within a health care delivery system.