Physician Advisor

Brigham and Women's Hospital
United States, Massachusetts, Boston
1153 Centre Street (Show on map)
Jul 02, 2025
Position Summary: The Physician Advisor (P.A.) is responsible for managing the efficiency of care delivered BWFH and is accountable to the BWH/BWFH Vice President of Inpatient Services and MGB Medical Director - Utilization Management. The role will also work closely with the BWH/BWFH Physician Advisor who has oversight for Utilization Management across the two campuses. By working with BWFH medical staff leadership, attending physicians, hospitalists, house staff, advanced practice practitioners, and care coordination, the P.A. will develop and implement methods to optimize the use of hospital services for all patients while ensuring high-quality care is provided. This includes working with Utilization Management nurses and Care Coordination nurses to ensure the appropriate level of care is assigned to every patient encounter. The P.A. should understand regulatory expectations for hospital care and provide ongoing surveillance of the reimbursement environment. Essential Functions Utilization Management: 1.Ensures accuracy in leveling and compliance with medical necessity rules. 2.Works with MGB Medical Director - Utilization Management, Director of Care Coordination, and inpatient and outpatient stakeholders to develop consistent policies and processes related to leveling of care. 3.Serves on the Utilization Review Committee and as a resource for Physicians, APPs, and other stakeholders. Reviews appropriate level of care as escalated by UM nurses and Care Coordination nurses. 4.Understands and uses medical necessity criteria. Ensures hospital compliance with CMS rules under the guidance of Brigham Health and MGB UM 5.Consults about clinical appropriateness of outside transfer requests and adjudicates related issues. 6.Reviews UM metrics monthly and reports metrics and proposed interventions during quarterly URC Faulkner meeting, which is attended by Faulkner hospital leadership 7.Provides backup support for the Medical Director of Utilization Management in an ad hoc fashion. Clinical Effectiveness: 1.Provides consultation to nurses and care coordination staff regarding complex clinical issues and advises on next steps. 2.Reviews issues identified by care coordinators to ensure appropriate follow-up. 3.Recommends improvement initiatives as needed and makes referrals to appropriate medical staff leadership. Denial and Appeal Management: 1.Develops and maintains positive relationships with third-party payers. Ensures processes are followed according to policies and contracts. 2.Communicates with the payer's P.A. as requested necessary to resolve any disputes surrounding medical necessity approvals for continued stay. 3.Supports primary clinical attending and provides coaching when necessary, when engaging in peer-to-peer discussions with payers. 4.Provides backup for primary clinical attendings when they are unable to perform peer-to-peer reviews 5. Reviews cases that indicate a need for issuance of a hospital notice of non-coverage. Discusses the case with the attending physician if needed and if additional clinical information is not available, discusses the process for issuance and appeal to the physician 6.Evaluates denials and responds with sound clinical rationale when appeal is warranted. Provides consultation to appeals staff and signs appeal letters. 7.Identifies denial trends and works the medical staff and hospital administration to resolve the issues. 8.Presents cases for appeal at ALJ hearings. Education / Communication: 1.Educates and engages with various ED and inpatient subspecialities and their leaders regarding UM goals and initiatives. 2.Collaborates with physicians and other clinical staff on patient issues that affect hospital payment before, during admission and after discharge. 3.Interacts with the medical staff to achieve optimal outcomes on case-specific issues. 4.Demonstrates excellent customer service and interpersonal skills. Qualifications / Skills / Knowledge Requirements: MD degree with current licensure. Completion of specialty residency, preferably in internal medicine, with subsequent board certification. Subspecialty or other post-residency fellowship is desirable but not required. 2-5 years of direct patient care within the last 5 years. Able educator with strong interpersonal, verbal, non-verbal, and written communication skills. 2-5 years of experience in a hospital-wide position involving quality management, utilization review, resource management, or medical staff governance. Proven ability to build rapport with medical staff management and management leadership. Knowledge of current medical literature, healthcare financial / reimbursement issues, the local and national regulatory environment, and medical staff organizations. Dedication to the delivery of high-quality, cost-effective, efficient patient care services. FTE Support: .15 CME: Allotment $2000 in year 1, $1000 in subsequent years Please email resumes to Thomas Walsh, twalsh1@bwh.harvard.edu . The Brigham and Women's Hospital, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.