The Physician Advisor plays a critical role in optimizing healthcare delivery by providing guidance on medical necessity, utilization management, and quality improvement initiatives. They collaborate with healthcare teams to ensure compliance with regulatory standards and promote cost-effective care delivery. This is a full-time position reports to the Chief Medical Officer. Candidates can inquire about part-time availability.
Key Functional Duties:
Utilization Review: Review medical records and documentation to assess the appropriateness of services rendered and ensure compliance with regulatory guidelines.
Medical Necessity Determination: Evaluate the medical necessity of procedures, treatments, and hospital admissions/level of care (Inpatient vs. observation) based on established criteria and guidelines.
Optimizing Discharge Planning: Collaborate with case managers, Social works, and healthcare providers to develop care plans that meet patients' clinical needs while optimizing resource utilization to improve Length of Stay. Work with the other stakeholders to optimize IDR
Denial Management: Lead the denial appeal process to optimize the resolution of insurance denials by providing clinical expertise and supporting appeals processes. The Physician advisor will identify trends in denial cases, perform root cause analysis, and develop actionable plans to prevent future denials. This includes providing targeted physician education on documentation best practices and ensuring alignment with appropriate ICD-10 coding and medical necessity criteria
Education and Training: Provide education and training to healthcare professionals on utilization management principles, documentation requirements, and regulatory compliance.
CDI: Collaborate with CDI to ensure appropriate physician documentation with a goal to improve utilization, CMI, and risk adjusted quality measures
Intradisciplinary Collaboration: Work closely with physicians, nurses, administrators, and other stakeholders to promote effective communication and coordination of care.
Policy Development: Contribute to the development and revision of utilization management policies, protocols, and procedures.
Leading the Utilization Management Committee
Performance Monitoring: Monitor and evaluate key performance indicators related to utilization management, quality of care, and financial outcomes.
Clinical duties: up to 25% of the position
Perform other duties as assigned by the CMO
Required Qualifications
Medical degree (MD or DO)
Medical license
Knowledge of utilization management principles, regulatory requirements, and healthcare economics.
Strong analytical skills and attention to detail.
Excellent communication and interpersonal skills.
Ability to work independently and collaboratively in a fast-paced environment.
Preferred Qualifications
Experience with electronic health records (EHR) and healthcare information systems.
Clinical experience in a hospital or healthcare setting.
Total compensation of $275,000 - $325,000.
About UsSkills Required
- Medical degree (MD or DO)
- Active medical license
- Knowledge of utilization management principles
- Knowledge of regulatory requirements
- Knowledge of healthcare economics
- Strong analytical skills and attention to detail
- Excellent communication and interpersonal skills
- Ability to work independently and collaboratively in a fast-paced environment
- Experience with electronic health records and healthcare information systems
- Clinical experience in a hospital or healthcare setting
What We Do
SUNY Downstate Health Sciences University is Brooklyn’s only academic medical center and part of the State University of New York. Through five schools and University Hospital at Downstate, it educates physicians, nurses, scientists, public-health leaders, and allied health professionals; advances biomedical, healthcare, and public-health research; and delivers patient-centered care while promoting health equity for New York’s diverse communities across the borough.
