Full Time Physician Advisor Utilization Review Jobs

Salary Range: $100.00 - $250.00

The Lead Physician Advisor serves as a Washington Health leader by ensuring the appropriate use of medical resources, optimizing patient care, and maintaining compliance with regulatory standards. This position involves a comprehensive understanding of clinical practices, an ability to analyze complex medical data, and effectively communicating findings and recommendations. The Lead Physician Advisor evaluates patient medical records to confirm that hospital admissions, procedures, and treatments are necessary, and adhere to established guidelines. The Physician Advisor also collaborates closely with healthcare providers, including physicians, nurses, case managers, clinical documentation integrity (CDI), specialists, other CDI leadership and personnel to discuss cases and offer clinical insights that ensure the best patient outcomes while managing resources efficiently. Additionally, the Lead Physician Advisor's involvement in interdisciplinary teams, including utilization review committees and quality improvement initiatives, underscores their commitment to enhancing patient care and resource utilization.

Statement of Accountability

The Lead Physician Advisor reports to the AV, Chief Quality Officer including a dotted line to the Director of Case Management and Director of HIM. The Lead Physician Advisor will be part of a larger group comprising the Lead Physician Advisor team under the direction of the Chief Physician Executive and Strategy Development. Additionally, they closely collaborate with and demonstrate leadership with providers, other Washington Health Medical staff, affiliated providers, leadership and other stakeholders.

Qualifications

Education

Licensure

Work Experience

Skills/computer/ specific technical

Other qualifications, miscellaneous

Specify if qualifications are required or preferred

Education:

Required: Medical Doctorate (MD)

Certifications:

Preferred: Physician Advisor

Work Experience:

Required:

Current unrestricted physician license in the State of California.

Minimum of five (5) years of active clinical practice experience.

Minimum of three (3) years of experience in physician advisor, utilization management, Case Management, Clinical Documentation Integrity (CDI), or related leadership role preferred.

Active medical staff at Washington Health

Comprehensive knowledge of Medicare, Medicaid, commercial payer regulations, and utilization review requirements.

Ability to demonstrate expertise in medical necessity criteria, including InterQual and/or MCG guidelines.

Strong understanding of inpatient, observation and outpatient status determination processes.

Experience managing peer-to-peer reviews with payers and successfully overturning denials.

Knowledge of CMS Conditions of Participation, The Joint Commission standards, and state regulatory requirements.

Experience collaborating with Case Management, Clinical Documentation Integrity (CDI), Revenue Cycle, Quality and Medical Staff leadership.

Demonstrates ability to educate physicians regarding documentation requirements, admission status, length of stay management and regulatory compliance.

Strong analytical skills with the ability to interpret utilization, denials, length of stay, case mix index and throughput data.

Experience leading multidisciplinary teams and driving organizational performance improvement initiatives.

Excellent verbal and written communication skills, including presentation of complex clinical and regulatory concepts to physicians, executives, and governing bodies.

Ability to influence physician practice patterns through collaborative and evidence-based approaches.

Knowledge of value-based purchasing, quality metrics, readmissions reduction and population health initiatives.

Demonstrates ability to resolve conflicts and facilitate consensus among physicians and interdisciplinary teams.

Experience participating in medical staff committees, utilization management committees, and quality improvement programs.

Proficiency with electronic health records (EHRs), clinical documentation systems, and data analytics tools.

Ability to maintain confidentiality and exercise sound professional judgment.

Strong organizational skills with the ability to manage multiple priorities in a fast-paced healthcare environment.

Essential Job Responsibilities

Achieving Results

Key Components: assess, plan, evaluate, demonstrate initiative, quality of work, productivity

The Lead Physician Advisor will be responsible for the following:

Review patient medical records to assess the necessity and appropriateness of hospital admissions, continued stays, and clinical procedures, as well as handle second-level reviews and appeals for cases requiring additional clinical expertise or cases contested by insurers.

Serve as a clinical liaison between the utilization management and CDI teams, medical staff and hospital administration, facilitating clear and effective communication across departments.

Educate medical staff by offering direction on optimal resource utilization, ensuring compliance with clinical standards, and advocating for best practices to improve patient care and operational effectiveness.

Collaborate with case managers, social workers, CDI specialist and discharge planners to ensure coordinated care transitions and efficient discharge planning. Act as a resource for clinical staff, providing guidance on best practices and resolving complex clinical utilization an documentation issues.

Support Medicare requirements by ensuring compliance with CMS guidelines through active participation in the Utilization Management Committee.

Chairs weekly Complex Case meeting, including follow up action items

Conduct peer-to-peer coaching and education to resolve denial cases, ensuring accurate and efficient healthcare utilization and patient care.

Develop and conduct training programs for physicians, nurses, and other healthcare professionals on utilization management principles, clinical documentation improvement, and regulatory requirements. Provide ongoing education and support to ensure clinical staff are knowledgeable about and adhere to utilization management policies and clinical documentation integrity policies, procedures, and best practices.

Demonstrates Skill

Key Components: competency, job knowledge, organizational skills, analytical skill, management of information, employee & patient safety

Demonstrates expert knowledge of utilization management, medical necessity determination, clinical documentation integrity, case management, and compliance.

Applies sound clinical judgment and evidence-based decision-making when evaluating patient status, resource utilization, and medical necessity.

Maintains competency in InterQual, MCG, CMS regulations, payer requirements, and applicable accreditation standards.

Effectively prioritizes responsibilities and manages multiple concurrent projects, reviews, and organizational initiatives in a timely manner.

Demonstrates strong organizational skills with the ability to manage complex cases, competing priorities, and critical deadlines.

Utilizes data and analytics to identify trends, evaluate performance, and develop strategies for process improvement and operational excellence.

Interprets clinical, financial, and operational data to support utilization management, denial prevention, quality improvement, patient throughput initiatives, and CDI.

Demonstrates effective problem-solving skills and exercises independent judgment when addressing complex utilization and documentation issues.

Maintains accurate, complete, and timely documentation in accordance with organizational, regulatory, and payer requirements.

Safeguards confidential patient, physician, and organizational information in compliance with HIPAA and hospital policies.

Demonstrates proficiency with electronic health records (EHRs), utilization review platforms, clinical documentation systems, and data reporting tools.

Communicates clinical and regulatory information clearly and effectively to physicians, leadership, and interdisciplinary team members.

Promotes a culture of patient safety, quality care, and regulatory compliance through physician engagement and collaboration.

Identifies potential patient safety concerns, barriers to care, and quality issues and facilitates appropriate intervention and escalation.

Supports initiatives that improve care coordination, reduce preventable harm, enhance patient outcomes, and optimize resource utilization.

Demonstrates accountability, professionalism, and leadership while serving as a trusted advisor to physicians, staff, and organizational leadership.

Fosters a safe work environment by adhering to organizational safety policies and supporting employee health and safety practices.

Maintains competency through ongoing education, professional development, and participation in quality and performance improvement activities.

Planning & Coordinating

Key Components: delegates, decision making, problem solving, management of resources

Expected to participate in and contribute to quality improvement projects and initiatives to enhance patient care, optimize resource utilization, and reduce healthcare costs. The Physician Advisor will monitor key performance indicators and develop action plans to address areas of concern. They will engage in continuous professional development and stay abreast of emerging trends and best practices in utilization management and healthcare quality improvement, and CDI.

Expected to ensure that communication of vital organizational priorities reaches the front-line staff of each physician clinical group.

Professionalism

Key Components: dependability, interpersonal skills, teamwork, patient first ethic, customer service, communication skills, punctuality/attendance, receptiveness to criticism, judgment, confidentiality

The Lead Physician Advisor is expected to:

Foster a collaborative, positive, and supportive working and clinical environment.

Display evidence-based decision-making.

Exemplify exceptional leadership by maintaining a strong presence across the healthcare system, ensuring the highest standards of patient care and seamless and efficient team coordination.

Demonstrate commitment to inclusion, communication, collaboration, and teamwork.

Excel in collaborative and front-line decision-making, working closely with all members of the team to ensure strategic and effective healthcare operations.

Improving the Organization

Key Components: performance improvement, quality initiatives

Leads and participates in hospital-wide performance improvement initiatives designed to enhance quality, patient safety, regulatory compliance, and operational efficiency.

Utilizes data analytics to identify opportunities for improvement related to medical necessity, length of stay, denials management, documentation quality, and resource utilization.

Collaborates with Case Management, Clinical Documentation Integrity (CDI), Quality, Revenue Cycle, and Medical Staff leadership to achieve organizational goals.

Monitors utilization management/CDI metrics and develops action plans to address identified performance gaps.

Participates in multidisciplinary committees and workgroups focused on quality outcomes, patient throughput, value-based care, and regulatory readiness.

Supports organizational initiatives aimed at reducing avoidable denials, improving case mix index (CMI), reducing length of stay, and optimizing reimbursement.

Promotes evidence-based practices and physician engagement to improve patient outcomes and organizational performance.

Provides recommendations to leadership regarding process improvements and best practices related to utilization management/CDI and physician advisor services.

Self-Development

Key Components: maintain license/certification, education and training

Maintains current unrestricted physician licensure and board certification in accordance with applicable regulatory and medical staff requirements.

Maintains Physician Advisor certification or pursues advanced education and certification related to utilization management, clinical documentation integrity, quality, and healthcare compliance.

Completes all required hospital, medical staff, regulatory, and departmental education and training programs within established timeframes.

Remains current with evolving healthcare regulations, payer requirements, medical necessity criteria, and industry best practices.

Participates in continuing medical education (CME) activities to maintain clinical expertise and professional competency.

Attends relevant conferences, seminars, and professional association meetings to enhance knowledge and leadership effectiveness.

Actively seeks opportunities for professional growth, leadership development, and continuous learning.

Serves as a resource and mentor to physicians, case managers, and interdisciplinary team members regarding utilization management and documentation practices.

Regulatory Compliance

Key Components: TJC, Title 22, OIG, HIPAA, State/Federal laws, hospital policies

Ensures compliance with all applicable federal, state, and local laws, regulations, and accreditation standards related to utilization management and physician advisor functions.

Maintains working knowledge of The Joint Commission standards, California Title 22 regulations, HIPAA requirements, CMS Conditions of Participation, and Office of Inspector General (OIG) guidance.

Adheres to all hospital policies, medical staff bylaws, rules, and regulations.

Supports regulatory surveys, audits, and accreditation activities by providing physician advisor expertise and documentation as required.

Ensures patient confidentiality and privacy are maintained in accordance with HIPAA and organizational policies.

Promotes appropriate documentation, medical necessity determination, and utilization review practices consistent with regulatory and payer requirements.

Identifies and reports compliance concerns, potential regulatory risks, and opp...