Physician Advisor

The Physician Advisor (PA) role is responsible for completing detailed reviews of complex patient cases to ensure appropriate plan of care and resource management. An enhanced case review by the PA is necessary to reduce denials and resource utilization issues. PA responsibilities include but are not limited to enhanced utilization review, comprehensive management of denials and appeals, effective partnership with Care Management and Social Work, expertise in insurance regulation and compliance, and availability for provider education.

The Physician Advisor works primarily Tuesday & Thursday 1:30pm-6:30pm

Occasional calls off-hours if major, time-sensitive issues should arise

May work other hours to assure UM program elements are in place and functioning off-hours

Responsibilities
Utilization Management - Participate in twice-daily observation huddles to support appropriate patient status determinations and address barriers to conversion or discharge. - Review observation cases for medical necessity and apply CMS Two-Midnight Rule criteria when appropriate. - Conduct admission reviews, continued stay reviews, second-level reviews, Medicare short-stay reviews, pre-bill/post-bill reviews, and readmission reviews. - Provide physician and staff education regarding utilization management, medical necessity requirements, and patient status determination. - Collaborate with Emergency Department physicians, Utilization Review, and Case Management teams regarding status determination and alternative levels of care. - Consult with providers regarding documentation deficiencies affecting medical necessity determinations. - Perform medical necessity appeals and peer-to-peer reviews with commercial and governmental payers. - Lead and support denial prevention, denial management, and appeals initiatives. - Serve as a liaison between providers and payers to facilitate approvals and reduce denials. - Support and participate in Utilization Management Committee activities. - Ensure compliance with CMS regulations, payer requirements, and utilization management best practices. Throughput & Length of Stay Management - Participate in bi-weekly Long Length of Stay (LOS) meetings to identify barriers to care and facilitate discharge planning. - Participate in daily escalation huddles to address patient flow challenges. - Collaborate with hospital leadership, physicians, nursing, and care management teams to improve patient throughput and reduce avoidable delays. - Provide feedback to physicians regarding level-of-care determinations, length of stay performance, and quality outcomes. - Assist providers in improving clinical documentation to support appropriate reimbursement and regulatory compliance. - Recommend evidence-based care strategies and next steps in coordination of care. - Promote interdisciplinary communication, collaboration, and care coordination. - Support organizational quality improvement initiatives requiring physician leadership and participation. Leadership & Physician Engagement - Serve as a resource to physicians regarding federal and state utilization, quality, and regulatory requirements. - Educate providers regarding documentation requirements, medical necessity criteria, and payer expectations. - Participate in hospital committees focused on evidence-based medicine, quality improvement, and patient outcomes. - Develop and support clinical protocols that promote optimal standards of care. - Present utilization management, quality, and performance improvement initiatives to Medical Staff, Administration, and the Board as needed. - Perform additional duties and special projects in support of organizational goals.

Qualifications
Education - Graduate of an accredited medical school. - Additional education or training in Quality Management, Utilization Management, or related disciplines preferred. Experience - Minimum of five (5) years of recent clinical practice experience. Licensure - Current and unrestricted New Jersey physician license required. Preferred Qualifications - Strong clinical judgment and medical decision-making skills. - Knowledge of care management principles, utilization review processes, and acute care medical necessity criteria. - Familiarity with commercial payer requirements and medical necessity guidelines. - Experience with concurrent and retrospective denials management and appeals. - Understanding of the clinical, quality, and administrative aspects of healthcare delivery. - Familiarity with clinical documentation improvement initiatives. - Working knowledge of CMS regulations, The Joint Commission standards, and New Jersey Department of Health requirements. - Excellent written, verbal, presentation, and interpersonal communication skills. - Strong teaching, coaching, and physician engagement abilities. - Exceptional analytical, critical-thinking, and problem-solving skills. - Knowledge of process improvement methodologies. - Ability to build collaborative relationships across multidisciplinary teams. - Clinical credibility and ability to influence physicians and healthcare leaders. - Energetic, engaging, and solution-oriented leadership style. - Strong organizational skills with the ability to drive initiatives to completion. Candidates who may not possess every preferred qualification but demonstrate the aptitude and commitment to develop these competencies are encouraged to apply.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.