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 PA conducts clinical reviews on cases referred by care management staff, physicians, and/or other health care professionals to meet regulatory requirements and in accordance with the hospital’s objectives for assuring quality patient care and effective, efficient utilization of health care services. The PA meets regularly with care management and health care team members to discuss selected cases and make recommendations for care, interacting with medical staff members, service line medical directors and medical directors of third-party payers to discuss the needs of patients and alternative levels of care. The PA acts as consultant to and resource for attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources. The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations. The PA will assist providers to accurately document the patient’s medical necessity and opportunities for conversions. PAs will help appropriately manage patients’ course of treatment to ensure expedited level of care.

The Physician Advisor works primarily Tuesday & Friday, 9am-2pm

Responsibilities
- Review admissions, continued stays, observations, and readmissions for medical necessity and compliance. - Apply the Two-Midnight Rule, payer guidelines, and manage denials and appeals. - Educate providers on documentation, patient status, and utilization management processes. - Participate in utilization management committees and escalate non-compliance trends. - Collaborate with leadership and care teams to optimize patient flow, length of stay, and quality outcomes. - Recommend evidence-based care coordination steps and support quality improvement initiatives. - Maintain compliance with CMS and regulatory standards. - Present to medical staff or administration and perform additional duties as assigned.

Qualifications
Education - Graduate of an accredited medical school required. - Additional training or education in Quality Management, Utilization Management, Care Management, or Healthcare Administration preferred. Experience - Minimum of five (5) years of recent clinical practice experience. - Prior experience in Utilization Review, Physician Advisory Services, Clinical Documentation Integrity (CDI), Care Management, Quality Improvement, or Healthcare Leadership is preferred. Licensure & Certifications - Current unrestricted New Jersey physician license required. - Board Certification in a recognized specialty preferred. Preferred Skills & Competencies The ideal candidate will possess: - Strong clinical judgment and decision-making abilities. - Knowledge of utilization review processes and acute care medical necessity criteria. - Familiarity with commercial payer requirements and Centers for Medicare & Medicaid Services (CMS) regulations. - Experience with concurrent and retrospective denials management and appeals. - Understanding of clinical documentation requirements and their impact on quality outcomes and reimbursement. - Knowledge of regulatory standards including CMS, The Joint Commission, and New Jersey Department of Health requirements. - Experience with process improvement and performance improvement initiatives. - Excellent analytical, critical thinking, and problem-solving skills. - Strong written, verbal, presentation, and interpersonal communication skills. - Ability to educate, coach, and influence physicians and interdisciplinary teams. - Collaborative approach with the ability to build strong partnerships across Care Management, Clinical Documentation Integrity, Quality, and Revenue Cycle teams. - Strong organizational skills with demonstrated ability to manage multiple priorities and drive projects to completion. - Professional credibility, leadership presence, and the ability to effectively engage stakeholders at all levels of the organization. Note: Candidates who may not possess every preferred qualification but demonstrate a strong interest and aptitude for learning 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.