Physician Advisor- Utilization Management & Clinical ...

Employment Type:Full timeShift:Description:The Physician Advisor serves as a physician leader responsible for improving clinical documentation accuracy, case mix index (CMI), medical necessity compliance, utilization management, and hospital throughput.The Physician Advisor works collaboratively with physicians, case management, clinical documentation integrity (CDI), quality, and revenue cycle teams to ensure appropriate patient status determinations, documentation accuracy, regulatory compliance, and optimal use of hospital resources.This role provides in person, peer-to-peer physician engagement and education to support compliant documentation, reduce denials, decrease avoidable length of stay, and ensure appropriate utilization of hospital services.Key Responsibilities and Essential FunctionsClinical Documentation & Case MixPartner with CDI specialists to improve clinical documentation accuracy and completenessProvide physician-to-physician education on documentation requirements related to:Severity of illnessRisk of mortalityCC/MCC captureDRG assignmentAssist with case mix index (CMI) improvement initiativesReview complex cases for documentation opportunities that accurately reflect patient acuityUtilization Management & Length of Stay OptimizationProvide physician guidance for medical necessity determinationsReview cases for appropriate inpatient vs observation statusSupport case management staff with complex utilization reviewsConduct peer-to-peer reviews with payersCollaborate with care management teams to identify and address barriers to timely dischargeWork with clinical teams to reduce avoidable length of stay and excess daysParticipate in daily multidisciplinary rounds and discussions to address throughput challenges and delayed dischargesWork with our Internal Medicine Residents to teach them what a Physician Advisor does and how to align and balance patient care with the KPI’s the Physician Advisor works on to improve.Opportunity Days ReductionReview cases with extended length of stay to identify clinical, operational, or documentation barriers contributing to opportunity daysPartner with case management, nursing leadership, and service line leaders to address drivers of avoidable hospital daysProvide physician leadership in resolving delays related to:Clinical decision-makingDocumentation gapsDischarge readinessSpecialist consultation delaysSupport hospital initiatives aimed at improving patient flow and capacity managementDenials Prevention & AppealsReview payer denials related to:Medical necessityLevel of careDRG downgradesWrite and support clinical appeal lettersParticipate in denials management strategyIdentify systemic issues contributing to denials and implement improvement strategiesPhysician Engagement & EducationProvide education to medical staff on documentation, utilization management, and efficient care deliveryPresent findings at:Medical staff meetingsService line meetingsQuality committeesServe as a physician champion for documentation improvement, medical necessity compliance, and hospital throughputQuality & ComplianceEnsure hospital practices align with:CMS Conditions of ParticipationMedicare documentation rulesTwo-midnight ruleUtilization review regulationsPartner with Quality and Compliance departments to ensure regulatory alignmentData Review & Performance ImprovementMonitor, analyze, and actively strive to improve key hospital performance metrics including, but not limited to:Case Mix Index (CMI)Length of Stay Index (Observed vs Expected LOS and %GMLOS)Opportunity DaysObservation ratesMedical necessity denial ratesCC/MCC capture rateIdentify opportunities for clinical, operational, and documentation improvementQualifications:RequiredMD or DO degree from an accredited institutionBoard Certified in a recognized medical specialtyActive unrestricted medical license to practice medicine in the state of Georgia.Minimum of 5 years clinical practice experienceExperience working in hospital-based careDemonstrated leadership, people management, and team building skillsMust have excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.Ability to develop and implement strategic clinical plansExcellent oral and written communication skillsAbility to interact effectively with key internal and external constituents using collaboration and customer service skills that promote excellence in the patient experience. Customer service orientationDemonstrated confidence, initiative, and integrity in work practicesGoal-directed and well organizedHigh level of dependability and accuracyAbility to work independentlyStrong negotiation and persuasion skillsAdept at conflict managementAbility to function within a stressful environmentStrong computer skills and working knowledge of EMR’sA broad knowledge base of health care delivery and case management within a managed care environmentComprehensive knowledge of Utilization Review, levels of care, and observation statusPreferredPrior experience as a Physician Advisor, Medical Director, or Utilization Review physicianExperience with:Clinical Documentation Integrity (CDI)Utilization ManagementRevenue cycle operationsDenials managementLength of stay improvement initiativesKnowledge of:MS-DRG reimbursementCase Mix IndexCMS inpatient admission criteriaCertification such as:CHCQM-PHYADV (Certified Physician Advisor)Additional advanced degree (MBA, MPH, MMM, etc)Awareness of healthcare reimbursement systems (HMO, PPO, PPS,CMS)Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Created: 2026-04-06