Physician Advisor- Utilization Management & Clinical Documentation Integrity

THIS IS A 1099 POSITION

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 Functions

Clinical Documentation & Case Mix

• Partner with CDI specialists to improve clinical documentation accuracy and completeness
• Provide physician-to-physician education on documentation requirements related to:
  • Severity of illness
  • Risk of mortality
  • CC/MCC capture
  • DRG assignment
• Assist with case mix index (CMI) improvement initiatives
• Review complex cases for documentation opportunities that accurately reflect patient acuity

Utilization Management & Length of Stay Optimization

• Provide physician guidance for medical necessity determinations
• Review cases for appropriate inpatient vs observation status
• Support case management staff with complex utilization reviews
• Conduct peer-to-peer reviews with payers
• Collaborate with care management teams to identify and address barriers to timely discharge
• Work with clinical teams to reduce avoidable length of stay and excess days
• Participate in daily multidisciplinary rounds and discussions to address throughput challenges and delayed discharges
• Work 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 Reduction

• Review cases with extended length of stay to identify clinical, operational, or documentation barriers contributing to opportunity days
• Partner with case management, nursing leadership, and service line leaders to address drivers of avoidable hospital days
• Provide physician leadership in resolving delays related to:
  • Clinical decision-making
  • Documentation gaps
  • Discharge readiness
  • Specialist consultation delays
• Support hospital initiatives aimed at improving patient flow and capacity management

Denials Prevention & Appeals

• Review payer denials related to:
  • Medical necessity
  • Level of care
  • DRG downgrades
• Write and support clinical appeal letters
• Participate in denials management strategy
• Identify systemic issues contributing to denials and implement improvement strategies

Physician Engagement & Education

• Provide education to medical staff on documentation, utilization management, and efficient care delivery
• Present findings at:
  • Medical staff meetings
  • Service line meetings
  • Quality committees
• Serve as a physician champion for documentation improvement, medical necessity compliance, and hospital throughput

Quality & Compliance

• Ensure hospital practices align with:
  • CMS Conditions of Participation
  • Medicare documentation rules
  • Two-midnight rule
  • Utilization review regulations
• Partner with Quality and Compliance departments to ensure regulatory alignment

Data Review & Performance Improvement

• Monitor, 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 Days
  • Observation rates
  • Medical necessity denial rates
  • CC/MCC capture rate
• Identify opportunities for clinical, operational, and documentation improvement

Qualifications:

Required

• MD or DO degree from an accredited institution
• Board Certified in a recognized medical specialty
• Active unrestricted medical license to practice medicine in the state of Georgia.
• Minimum of 5 years clinical practice experience
• Experience working in hospital-based care
• Demonstrated leadership, people management, and team building skills
• Must 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 plans
• Excellent oral and written communication skills
• Ability to interact effectively with key internal and external constituents using collaboration and customer service skills that promote excellence in the patient experience.

• Customer service orientation
• Demonstrated confidence, initiative, and integrity in work practices
• Goal-directed and well organized
• High level of dependability and accuracy
• Ability to work independently
• Strong negotiation and persuasion skills
• Adept at conflict management
• Ability to function within a stressful environment

Strong computer skills and working knowledge of EMR’s

• A broad knowledge base of health care delivery and case management within a managed care environment
• Comprehensive knowledge of Utilization Review, levels of care, and observation status

Preferred

• Prior experience as a Physician Advisor, Medical Director, or Utilization Review physician
• Experience with:
  • Clinical Documentation Integrity (CDI)
  • Utilization Management
  • Revenue cycle operations
  • Denials management
  • Length of stay improvement initiatives
• Knowledge of:
  • MS-DRG reimbursement
  • Case Mix Index
  • CMS inpatient admission criteria

• Certification 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.