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Job Description
The Physician Advisor provides physician-to-physician reviews, clinical guidance, education, and escalation support while promoting evidence-based practices and appropriate resource utilization.
Key Responsibilities
- Conduct physician-to-physician reviews for medical necessity, level of care, and denial prevention/appeals
- Support utilization review and case management teams with complex clinical decision-making
- Ensure appropriate admission status determinations (inpatient vs. observation) in alignment with CMS and payer guidelines
- Provide clinical oversight related to length of stay, care progression, and discharge planning
- Ensure adherence to CMS Conditions of Participation, Medicare regulations, and payer policies
- Support compliance with medical necessity criteria (InterQual, MCG, or equivalent)
- Assist with audit preparedness and response, including RAC, MAC, and commercial payer audits
- Partner with HIM/CDI teams to improve documentation quality and clinical accuracy
Education & Physician Engagement
- Serve as a trusted peer resource to attending physicians and advanced practice providers
- Educate medical staff on regulatory requirements, utilization best practices, and documentation standards
- Support change management initiatives related to clinical operations and compliance
Qualifications
Required
- MD or DO with an active, unrestricted medical license
- Board-certified or board-eligible in a recognized specialty
- Clinical practice experience in an acute care or relevant healthcare setting
- Strong knowledge of utilization management, medical necessity, and payer regulations
- Excellent communication skills with the ability to conduct peer-to-peer discussions
Preferred
- Prior experience as a Physician Advisor, Medical Director, or in Utilization Review
- Familiarity with CMS guidelines, InterQual, MCG, and denial management processes
- Experience working with case management, CDI, HIM, or revenue cycle teams
- Experience in a remote or consulting healthcare environment
Skills & Competencies
- Physician-to-physician negotiation and collaboration
- Clinical judgment balanced with regulatory and financial awareness
- Data-driven decision-making
- Ability to influence without authority
- Strong written and verbal communication