Physician Advisor
Job Description
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
- 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.
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.
St. Joseph’s Health is recognized for the expertise and compassion of its highly skilled and responsive staff. The combined efforts of the organization’s outstanding physicians, superb nurses, and dedicated clinical and professional staff have made us one of the most highly respected healthcare organizations in the state, the largest employer in Passaic County, and one of the nation’s “100 Best Places to Work in Health Care”.
Benefits Eligibility: (Full-time and Part-time Employees-over 20 hours a week)
- Competitive salary*
- Robust benefits with health, dental, Rx and vision plans
- 403b retirement plan options with company match**
- Health & Wellness*
- Non-Profit Health System – eligible for Federal Student Loan Forgiveness
- PTO, and paid holidays
- Tuition reimbursement
- Employee Assistance Program
- LTD : Long Term Disability
- Life Insurance Options
- Onsite Day care Program
*Available for Per Diem Employees and Part-time Employees working under 20 hours per week.
**403b Company Match not applicable for Per Diem Employees and Part-time Employees working under 20 hours per week.
Pay transparency: St. Joseph’s Health provides a salary range to comply with New Jersey Law. The rate of pay for each position will be determined based on a variety of factors including the candidate's relevant experience, qualifications, skills, etc.” The salary range does not include incentives, differential pay or other forms of compensation.