Remote Physician Advisor Utilization Review Jobs

System Physician Advisor Medical Director Responsibilities and Job Description

Overview:

The Lee Health System Physician Advisor Medical Director reports to the Chief Physician Executive for Hospital-Based Care and works closely with the Chief Medical Officer, Chief Nursing and Operational Executives of the Lee Health hospitals, Chief Financial Officer, Chief Technology Officer, medical staff leadership, and other leadership related to case/utilization management and revenue cycle including the Lee Health Physician Advisors.

The primary role of the System Physician Advisor Medical Director is to monitor and foster optimization of all aspects of health system resource management, utilization management, care management (including discharge planning), and social services for all patients while ensuring the highest quality of care is provided. This includes working with health system and hospital leadership to ensure efficient management and delivery of resources, developing case management protocols to optimize length of hospital stay, effectively identify elements of medical necessity for patient placement in appropriate levels of care and patient status, support documentation integrity and compliance, and monitor the appropriate use of diagnostic and therapeutic modalities. Working in tandem with the physician advisors, the System Physician Advisor Medical Director is an expert in Centers for Medicare and Medicaid Services (CMS) rules and regulations related to patient status, clinician documentation, medical necessity, provision of services, and other topics related to case/utilization management.

Responsibilities:

This is meant to be a general list of responsibilities, not an exhaustive list. The breadth of the System Physician Advisor Medical Director responsibilities is large; focus on the individual responsibilities below will vary depending upon organizational priorities. The System Physician Advisor Medical Director will also perform other reasonably related business/job duties as assigned. Lee Health reserves the right to revise job duties and responsibilities as the need arises.

Utilization

• Review medical records of patients referred by physician advisors to require escalation and additional insight regarding quality, utilization, and patient status oversight.
• Drive educational and corrective actions to ensure clinicians are not contributing to payer medical necessity/status denials or governmental non-compliance.
• Analyze and report on trends related to lack of medical necessity, delays in progression of care, Medicare Condition Code 44, Medicare Condition Code W2 (Medicare Part B rebilling), payer medical necessity denials, etc.
• Investigate avoidable delay concerns referred by physician advisors to require escalation and additional insight regarding patient outcomes during their hospital stay.
• Work with medical staff leadership to provide regular feedback to clinicians regarding patient status assignment, length of stay, quality of care, or other identified opportunities.
• Act as physician representation supporting the organization in reviewing and refuting regulatory reviews for Inpatient medical necessity (e.g., Recovery Audit Contractor (RAC), Quality Improvement Organization (QIO), etc.).

In collaboration with Utilization Management leadership, develop and maintain effective working relationships with contracted providers involved in remote utilization review and physician advisory services.

• Serve as chair of the Lee Health Utilization Review Committee.
• Collaborate with the Chief Technology Officer on technology solutions to optimize workflows for medical and other staff.
• Collaborate with Utilization Management, Case Management, Quality Documentation, and Revenue Cycle leadership along with physician advisors to optimize case/utilization/denial management and quality documentation workflows.

Denial Management

Work with physician advisors, Revenue Cycle, Patient Financial Services (PFS), and Utilization Management teams to assess payer denial trends and collaborate in remediation efforts.

In collaboration with physician advisors, Utilization Review, Revenue Cycle, and Payer Contracting leadership, develop and maintain effective working relationships with payer representatives and vendors contracted to address payer denials for medical necessity.

Quality

• Analyze and report on trends related to quality, safety, and efficiency issues potentially leading to delivery of suboptimal care. Collaborate with pertinent health system and hospital leadership to address and create action plans to resolve.
• Support the organization in quality improvement efforts requiring clinician input and/or involvement.
• Participate in all organizational efforts to reduce hospital readmissions.
• Member of the Lee Health Medical Executive Committee.

Education

• Maintain knowledge of current state, federal, and CMS regulations, Quality Improvement Organization (QIO) requirements, and guidelines on case management and utilization review.
• In collaboration with the physician advisors, educate clinical providers regarding payer and CMS requirements including inappropriate hospitalizations, inappropriate Inpatient status designations, and payer and CMS criteria involving medical record documentation, appropriate utilization of hospital services, and alternative levels of care. Education may include presentations at department or division meetings, individual provider meetings, articles in entity-specific newsletters, or other communication vehicles as identified/developed.
• Educate, mentor, and provide action plans for clinical providers regarding payer and CMS requirements including inappropriate hospitalizations, inappropriate Inpatient status designations, and payer and CMS criteria involving medical record documentation, appropriate utilization of hospital services, and alternative levels of care.
• Educate teams (e.g., nursing, physical/occupational therapy, billing department, etc.) regarding care coordination and utilization management when needed.

Report practice pattern trends and opportunities to service line or department-specific meetings when needed.

Provide presentations to the medical staff, Lee Health board/administration as requested in relation to topics associated with physician advisory topics.

Report trends, data, and metrics to the Chief Operational Officer, Chief Medical Officer, Chief Physician Executive for Hospital-Based Care, Chief Nursing Officers, and Chief Financial Officer on a regular basis.

Develop an educational curriculum for all medical staff related to medical necessity, appropriate utilization of hospital resources, proper patient status placement, and optimization of documentation.

Administrative:

Report to the Lee Health Vice President/Chief Physician Executive of Hospital Based Services.

Receive report from the physician advisors.

Horizontal leadership with Case Management, Utilization Management, and Quality Documentation leaders.

Create and maintain the schedule and staffing of the physician advisors along with contracted external physician advisory services ensuring adequate physician advisor coverage.

Hold routinely cadenced meetings with the physician advisors (at least monthly) to review data and trends, identify opportunities for improvement or issues for escalation, and receive feedback.

The System Physician Advisor Medical Director may not serve in this role while serving in another Lee Health-related administrative role or while practicing clinically. The minimum FTE for this role is 1.0.

Routine hours will include Monday Friday, 8 AM 4 PM plus one weekend (Saturday and Sunday) 8 AM 4 PM at least once every 13 weeks. Weekend coverage will involve addressing escalationssent by case/utilization managersrelated to patients hospitalized at all Lee Health hospitals. Standard time off for holidays, vacation, and continuing medical education is provided as allowed per Lee Health policy.

Onsite presence with system leadership and/or with staff at individual hospitals is required at least three (3) days per week.

Administrative assistant support will be provided for this role.

Key Performance Indicators (KPIs):

1. Assessment of case escalations from physician advisors within one (1) business day of time sent to the System Physician Advisor Medical Director

2. Decrease in Medicare Condition Code W2s (Medicare Part B rebilling)

3. Compliance with Utilization Review Committee requirements per the Lee Health UM Plan.

2026/2027 Goals:

1. Decrease in care delays related to clinician/hospital limitations (e.g., discharge order not placed preventing discharge, cardiac stress test not performed due to holiday, etc.)

2. Collection of clinician outliers related to failed status change following utilization manager/physician advisor request with proposed plan of corrective action given to senior leadership

3. Creation of medical staff onboarding education related to patient status, medical necessity, collaboration with case/utilization managers, and physician advisors to start in 2027

Requirements:

• Licensed physician (MD/DO/MBBS).
• Holds a medical license in good standing in the State of Florida.
• At least five (5) years of experience in clinical practice, preferably in an inpatient hospital setting.
• American College of Physician Advisors Certified (ACPA-C) or American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) certification within twelve (12) months of hire if not already attained.
• Maintains current knowledge of state, federal, and payor regulatory and contract requirements along with familiarity in quality and utilization management topics via yearly continuing medical education programs and self-study.

Preferred applicants are well versed in the use of InterQual and MCG criteria.

Preferred applicants are well versed in the use of Epic.

• Experience with public speaking, clinical leadership, mentorship, addressing conflict and difficult conversations, and clinician coaching.
• Exceptional organization and time management skills.