Physician Advisor

***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

Originally posted on Himalayas