Physician Advisor

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