***WE ARE CURRENTLY FULLY STAFFED, BUT OUR NEEDS CAN CHANGE AT ANY TIME, AND WE ARE STILL ACCEPTING APPLICATIONS*** 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

Physician Advisor

similar openings