Utilization Manager Jobs in Lowell, IN (NOW HIRING)

We are seeking a detail oriented Physician Advisor to join our inpatient team full time. This role serves as a key clinical and operational leader, supporting effective utilization of healthcare services and ensuring compliance with payer and regulatory requirements. The Physician Advisor provides expertise in medical necessity, documentation, care progression, and denial management, working closely with Care Management, Utilization Review, Revenue Cycle, and hospital leadership. This position reflects rotating weekend call coverage.

Reporting to the Chief Medical Officer the Physician Advisor partners with medical staff leadership, providers, and resource management teams to optimize utilization practices and support organizational goals.

• Make recommendations on level of care including initial level of care, secondary review, and as requested by case management.
• Make recommendations for documentation improvement to ensure the medical record accurately reflects the patient’s clinical status, supports the level of care provided, and meets regulatory and payer requirements.
• Collaborate with providers to identify opportunities for enhanced documentation that clarifies the rationale for services rendered, severity of illness, and care progression, thereby reducing the risk of denials and facilitating appropriate reimbursement.
• Review daily level of care recommendations on cases placed in Observation.
• Participate in the denials management process and lead efforts to optimize denial management.
• Perform peer‑to‑peer appeals and draft appeal letters for third‑party denials where appropriate.
• Apply the 2‑midnight rule to Medicare reviews and maintain compliance with Medicare rules related to level of care recommendations.
• Stay current on changes in payer rules, including CMS rules, as they pertain to utilization review.
• Recommend additional and more complete medical record documentation from providers to support placement status or medical necessity.
• Understand and use InterQual, MCG, and other appropriate criteria.
• Apply medical expertise to assist with appropriate billing for services.
• Provide feedback on payer denial patterns where appropriate.
• Assist in supporting Length of Stay (LOS) strategies (avoidable days) and quality goals.
• Facilitate, mentor, and educate other physicians regarding documentation and payer requirements.
• Facilitate, mentor, and educate case management on the utilization review process where appropriate.
• Other duties as assigned to support the unit, department, entity, and health system organization.

• MD or DO
• Possess and maintain an unrestricted medical license in the State of Illinois

• Minimum 5 years clinical experience in a hospital setting
• Possess or develop a solid foundation in the areas of utilization management and hospital operations

• Palliative Care Fellowship
• American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) Health Care Quality and Management (HCQM) certification
• American College of Physician Advisors certification (ACPA-C)

Riverside Medical Group

350 N. Wall St. Kankakee, IL

Exposure to:

Chemicals: Refer to MSDS Sheets

Video Display Terminals: Average

Blood and Body Fluids: None

TB or Airborne Pathogens: None other than normal hospital environment exposure.

Sensory requirements (speech, vision, smell, hearing, touch):

Speech: Required to communicate during presentations/training, telephone communication, facilitate meetings, communication with providers and other staff.

Vision: Needed to read memos and literature, type correspondence from handwritten material and to coordinate calendars.

Smell: Helpful to note presence of electrical/fire safety.

Hearing: Needed for telephone communication, meetings, alarms and listening to employees/staff.

Touch: Needed to write, computer entry, filing.

Percentage of time during the normal workday the employee is required to:

Sit: 70%

Twist: 0%

Stand: 10%

Crawl: 0%

Walk: 15%

Kneel: 1%

Lift: 5%

Drive: 0%

Squat: 5%

Climb: 1%

Bend: 5%

Reach above shoulders: 0%

The weight required to be lifted each normal workday according to the continuum described below:

Up to 10 lbs: Occasionally

Up to 20 lbs: Occasionally

Up to 35 lbs: Occasionally

Up to 50 lbs: Not Required

Up to 75 lbs: Not Required

Up to 100 lbs: Not Required

Over 100 lbs: Not Required

Describe and explain the lifting and carrying requirements. (Example: the distance material is carried; how high material is lifted, etc.):

Maximum consecutive time (minutes) during the normal workday for each activity:

Sit: 120

Twist: 0

Stand: 30

Crawl: 0

Walk: 5

Kneel: 2

Lift: 1

Drive: 0

Squat: 5

Climb: 0

Bend: 5

Reach above shoulders: 2

Repetitive use of hands (Frequency indicated):

Simple grasp up to 1 lbs. Normal weight: frequent

Pushing & pulling Normal weight: 5 lbs frequent

Fine Manipulation: Moving charts, written documentation.

Repetitive use of foot or feet in operating machine control: None

Environmental Factors (Time Spent):

Inside hours: 8

Outside hours: 0

Temperature: Normal Range

Lighting: Average

Noise levels: Average

Humidity: Normal Range

Atmosphere: Normal Range

Special Hazards: None

Protective Clothing Required: None

USD $95.38 - USD $141.06 /Hr