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 Monday 1:30pm-6:30pm & Wednesday 9am-2pm

• 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, provider consultations, and escalation of barriers to conversion or discharge. - Review observation cases daily for medical necessity and apply the CMS Two-Midnight Rule 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 providers, Utilization Review, and Case Management teams regarding status determination and alternatives to acute care when appropriate. - Consult with providers regarding medical necessity documentation and identify trends or compliance concerns for escalation to the Utilization Management Committee. - Perform medical necessity appeals and peer-to-peer reviews across all payer groups. - Lead and support denial prevention, denial management, and appeals initiatives. - Serve as a liaison between providers and payers to facilitate approvals, reduce denials, and address payer-specific requirements. - Lead and/or support the hospital's Utilization Management Committee. - Maintain knowledge of and 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 meetings to identify barriers to care, establish LOS goals, and facilitate discharge planning. - Participate in daily escalation huddles to address patient flow and operational challenges. - Collaborate with hospital leadership, physicians, nursing, and care management teams to improve patient throughput and reduce avoidable delays. - Provide feedback and education to physicians regarding level of care determinations, length of stay performance, and quality outcomes. - Consult with providers to improve clinical documentation and support appropriate reimbursement and regulatory compliance. - Recommend evidence-based care strategies and next steps to support efficient patient progression. - Promote interdisciplinary collaboration, communication, and coordination across the healthcare team. - Support organizational quality improvement initiatives requiring physician leadership and participation. - Partner with Care Management and Utilization Management teams to provide physician education and support performance improvement efforts. Leadership & Administrative Responsibilities - Actively participate in hospital committees and multidisciplinary teams focused on evidence-based medicine, quality improvement, and patient care outcomes. - Develop and support clinical protocols that promote optimal standards of care and regulatory compliance. - Present utilization management, quality, and performance improvement initiatives to Medical Staff, hospital leadership, Board members, and administration as needed. - Serve as a physician leader and resource for utilization management, care coordination, and performance improvement initiatives. - Perform additional duties and special projects as assigned to support organizational goals and strategic priorities.

Qualifications
Education - Graduate of an accredited medical school. - Additional education in Quality Management and Utilization Management through continuing medical education programs and self-study 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 acumen and medical judgment. - Knowledge of care management principles, utilization review processes, and application of acute care medical necessity criteria. - Working knowledge of third-party payer guidelines and commercial payer medical necessity requirements. - Experience with concurrent and retrospective denials management and appeals. - Understanding of the clinical, quality, and administrative aspects of healthcare delivery. - Familiarity with clinical documentation requirements and best practices. - Working knowledge of Centers for Medicare & Medicaid Services (CMS), The Joint Commission, and New Jersey Department of Health regulations. - Excellent written, verbal, and presentation skills. - Strong teaching, coaching, and physician engagement abilities. - Exceptional analytical, critical thinking, and problem-solving skills. - Knowledge of process improvement methodologies and performance improvement initiatives. - Ability to foster collaborative relationships and partner effectively with multidisciplinary teams. - Clinical credibility and the ability to influence and engage physicians and healthcare leaders. - Persuasive, energetic, and personable leadership style with a positive and solution-oriented approach. - Strong organizational skills and demonstrated ability to drive projects and initiatives through completion. Candidates who may not possess every preferred qualification but demonstrate the aptitude, commitment, and willingness 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.