Physician Advisor

Physician AdvisorThe Physician Advisor provides physician-to-physician reviews, clinical guidance, education, and escalation support while promoting evidence-based practices and appropriate resource utilization.Key ResponsibilitiesConduct physician-to-physician reviews for medical necessity, level of care, and denial prevention/appealsSupport utilization review and case management teams with complex clinical decision-makingEnsure appropriate admission status determinations (inpatient vs. observation) in alignment with CMS and payer guidelinesProvide clinical oversight related to length of stay, care progression, and discharge planningEnsure adherence to CMS Conditions of Participation, Medicare regulations, and payer policiesSupport compliance with medical necessity criteria (InterQual, MCG, or equivalent)Assist with audit preparedness and response, including RAC, MAC, and commercial payer auditsPartner with HIM/CDI teams to improve documentation quality and clinical accuracyEducation & Physician EngagementServe as a trusted peer resource to attending physicians and advanced practice providersEducate medical staff on regulatory requirements, utilization best practices, and documentation standardsSupport change management initiatives related to clinical operations and complianceQualificationsRequiredMD or DO with an active, unrestricted medical licenseBoard-certified or board-eligible in a recognized specialtyClinical practice experience in an acute care or relevant healthcare settingStrong knowledge of utilization management, medical necessity, and payer regulationsExcellent communication skills with the ability to conduct peer-to-peer discussionsPreferredPrior experience as a Physician Advisor, Medical Director, or in Utilization ReviewFamiliarity with CMS guidelines, InterQual, MCG, and denial management processesExperience working with case management, CDI, HIM, or revenue cycle teamsExperience in a remote or consulting healthcare environmentSkills & CompetenciesPhysician-to-physician negotiation and collaborationClinical judgment balanced with regulatory and financial awarenessData-driven decision-makingAbility to influence without authorityStrong written and verbal communication