Director Utilization Management Jobs in Virginia

City/StateSuffolk, VAWork ShiftFirst (Days)Overview:Physician Advisor – Sentara Obici Hospital (Suffolk, VA)Make a broader impact beyond patient care and help shape healthcare delivery at Sentara Health.As a Physician Advisor, you'll leverage your clinical expertise to influence patient outcomes, support physician engagement, and drive quality, compliance, and operational excellence while partnering with physicians and leaders across the health system.The On-Site Physician Advisor at Sentara Princess Anne Hospital in Virginia Beach, Virginia, conducts timely and compliant medical necessity reviews and assists with denials management, including peer-to-peer discussions and appeal letters, in support of Sentara's centralized Utilization Review (UR) process.The Physician Advisor plays a critical role in ensuring appropriate patient status determinations, supporting compliant billing practices, and strengthening collaboration among Clinical Revenue Cycle, Utilization Review, Integrated Care Management (ICM), hospital leadership, and medical staff. This role interfaces directly with physicians and advanced practice providers, providing concurrent education and guidance regarding hospital status, regulatory requirements, documentation integrity, and medical necessity.Due to the highly collaborative and relationship-driven nature of the role, full-time on-site presence is required. Coverage at additional Sentara facilities may occasionally be required. This position reports to the Director of Regional Physician Advisors, Clinical Revenue Cycle.Key ResponsibilitiesPerform timely and compliant medical necessity reviews and provide clear documentation supporting regulatory requirements and status determinations.Facilitate denials management through case reviews, peer-to-peer discussions with payers, and assistance with appeal letter preparation.Collaborate with hospital leadership, medical staff, and ICM leaders to support system initiatives and performance goals.Attend and participate in Hospital Utilization Management (UM) Committees and other designated meetings.Provide education to physicians, leaders, and staff regarding utilization review, documentation integrity, and regulatory requirements.Complete required training and continuing education.Support additional responsibilities as appropriate to departmental and organizational needs.EducationDoctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school (Required)Completion of an accredited residency training program (Required)Licensure & CertificationActive and unrestricted Virginia medical license (Required)Board certification in specialty at time of hire (Required)ExperienceMinimum of 3 years of clinical experience required; hospital-based clinical experience preferred.Working knowledge of CMS regulations and requirements related to utilization review and site-of-service determinations.Knowledge of clinical documentation integrity (CDI), hospital billing and coding practices, case mix index (CMI), and DRG assignment methodologies.Familiarity with InterQual, MCG, or similar level-of-care criteria and the ability to apply clinical judgment in complex cases.Familiarity with hospital operations and case management processes.Strong customer service and interpersonal skills.Effective presentation and physician education skills.Excellent written and verbal communication abilities.Ability to manage competing priorities and work independently.Demonstrated flexibility, teamwork, and collaborative leadership.Proficiency with EMR systems and related technology tools.Keywords : #LI-AR2 ,Physician Advisor, Physician Executive, Medical Director, Utilization Management, Utilization Review, Medical Necessity Review, Clinical Documentation Integrity (CDI), Denials Management, Appeals Management, Peer-to-Peer Reviews, Revenue Cycle, Case Management, Care Management, Hospital Medicine, Internal Medicine, Family Medicine, Emergency Medicine, Physician Leadership, Healthcare Quality, CMS Regulations, InterQual, MCG, DRG, Hospital Operations, Medical Staff Engagement, Healthcare Compliance, Value-Based Care, Clinical Excellence, Physician Engagement, Virginia Beach, Virginia, Sentara Health, Hospital Leadership, Clinical Operations, Healthcare Administration..Benefits: Caring For Your Family and Your Career• Medical, Dental, Vision plans• Adoption, Fertility and Surrogacy Reimbursement up to $10,000• Paid Time Off and Sick Leave• Paid Parental & Family Caregiver Leave• Emergency Backup Care• Long-Term, Short-Term Disability, and Critical Illness plans• Life Insurance• 401k/403B with Employer Match• Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education• Student Debt Pay Down – $10,000•Pet Insurance•Legal Resources Plan•Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.Sentara Obici Hospital, a 175-bed state-of-the-art facility, is located on Godwin Boulevard in Suffolk, VA. Our full-service hospital continues a legacy of providing residents of Western Tidewater with high-quality, patient-centered care. As a recognized accredited Primary Stroke Center, and Magnet hospital for nursing excellence, the hospital specializes in orthopedic and spine, heart and vascular, advanced imaging, gynecological and comprehensive breast services, behavioral health, maternity, weight loss surgery, and a heartburn treatment center.Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.In support of our mission “to improve health every day,” this is a tobacco-free environment.For positions that are available as remote work, Sentara Health employs associates in the following states:Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. #J-18808-Ljbffr