Advanced Practice Provider Advisor

GENERAL SUMMARY:

Collaborates with Bryan Medical Center (BMC) providers, Utilization Management (UM), Revenue Integrity, and billing to ensure clinical information given to insurance companies is complete and appropriate. Performs clinical case status reviews and provides recommendations that focus on establishing the appropriate admission status according to guidelines set forth by Centers for Medicare and Medicaid Services (CMS). Assists UM and physician advisors in navigating complex and unexpected challenges, including major regulatory updates and downstream policy changes from Medicare and private payors, which can create significant financial strain. Provides measures to improve compliance and ensure appropriate payment for the care delivered. Analyzes appeal and denial claims alongside quality and performanceimprovement activities, then delivers targeted education to utilization review teams and providers on denial trends, clinical documentation improvement strategies, and evolving insurance guidelines.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, and beliefs and consistently demonstrates our core values.

2. *Performs peer-to peer conversations with Medicare Advantage, Medicaid health plans, and commercial payers per regulatory and contractual agreements.

3. *Conducts a primary medical necessity review on cases that are in observation status.

4. Maintains and navigates the APP Advisor work queue, Physician Advisor Navigator, and secondary review requests to determine case status, ensuring timely and accurate feedback on inpatient and observation reviews.

5. *Conducts first and second level medical necessity reviews for all patient cases that do not meet first level inpatient criteria.

6. Assists Utilization Management (UM) manager with UM education.

7. *Provides feedback to attendings and consulting physicians regarding clinical status decisions and documentation.

8. Communicates with physicians regarding escalated UM issues.

9. *Communicates with Senior Leadership and the UM Committee on issues that are not resolved at the APP Advisor to physician level.

10. *Drives physician, APP, and clinical staff education on documentation improvement, leading targeted training sessions that strengthen query volume, response rates, and agreement rates.

11. Assists UM manager with medical necessity meetings with the payers and attend payer representative meetings as directed.

12. *Provides metric and data information to UM managers and senior leadership on performance of UM.

13. Assists UM manager in coordination and facilitation of the Utilization Management Committee meeting each quarter.

14. Provides constructive feedback on queries, reviews, and performance in conjunction with the UM manager.

15. Participates in continuing education through RAC Relief google groups, BMC consulting initiatives and The American College of Physician Advisors (ACPA).

16. Obtains American College of Physician Advisors Certification (ACPA-C) within the first year of employment.

17. Remains current on all regulatory changes for CMS.

18. Reviews and works collaboratively with the UM manager on UM process/policies/improvements.

19. *Reviews and analyzes third-party vendor data reporting on ideas for improvement and cost savings.

20. *Research and compile underlying root causes of denials and strategies to prevent denials and improve clinical documentation.

21. *Tracks clinical documentation improvement metrics to monitor reimbursement and emerging trends.

22. *Collaborates with senior leadership, Clinical Documentation Integrity on creating order sets / smart phrases to improve documentation for providers that align with CMS regulations.

23. Available to receive emergent phone calls on weekends, holidays and after business hours.

24. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

25. Participates in meetings, committees, and department projects as assigned.

26. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk "*." Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES:

1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient's growth and developmental needs, annual skill competency verification and mandatory education and competencies.

2. Knowledge of and familiarity with current medical literature, healthcare reimbursement issues (i.e., medical necessity, levels of care, coding), MCG/Inter Qual screening criteria, Medicare/Medicaid compliance, and medical staff structure, policies, and procedures.

3. Knowledge of computer hardware equipment and software applications relevant to work functions.

4. Demonstrated ability to deliver high quality, cost-effective, efficient patient care services.

5. Ability to develop and maintain relationships.

6. Ability to build rapport with medical staff, third-party physician advisors, and hospital leadership.

7. Ability to task switch and prioritize assignments based on BMC and payor deadlines.

8. Ability to communicate effectively both verbally and in writing.

9. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff.

10. Ability to problem solve and engage independent critical thinking skills.

11. Ability to maintain confidentiality relevant to sensitive information.

12. Ability to prioritize work demands and work with minimal supervision.

13. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

Graduation from an accredited Physician's Assistant program required. Current licensure in the State of Nebraska as a Physician Assistant is required. Minimum of three (3) years of clinical Advanced Practice Provider experience and three (3) years of Utilization Management experience or equivalent required.

OR

Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required. Master of Science degree in Nursing with current Advanced Practice Registered Nurse licensure from the State of Nebraska required. Minimum of three (3) years of clinical Advanced Practice Provider experience or five (5) years' experience as a Registered Nurse and one (1) year of clinical Advanced Practice Provider experience and three (3) years of Utilization Management experience or equivalent required.

OTHER CREDENTIALS/CERTIFICATION:

Basic Life Support (CPR) certification is required. Bryan Health recognizes the American Heart Association (for healthcare professionals), the American Red Cross (for healthcare professionals), and the Military Training Network.

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.

(DOT) - Characterized as sedentary work requiring exertion of up to ten pounds of force occasionally and/or negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. Prolonged periods of standing, walking, and/or moving while making rounds within the Medical Center are typical.