Care Management & Utilization Management Physician Advisor

2600 White Plains Hospital Medical Center; Nevada (IA); On-site; USD 250,000 - 500,000; Full time

Job summary

White Plains Hospital Medical Center is seeking a Physician Advisor to lead clinical operations, drive documentation accuracy, and partner with CDI, Coding, and Quality teams to improve care outcomes. The role emphasizes collaboration across departments to ensure compliant, high-value care delivery.

The position requires MD/DO with active license, board certification, and a track record of leadership in hospital settings.

Qualifications

• MD/DO with active medical license in the state of employment.
• Board certification in a medical specialty.
• Minimum 10 years of clinical practice and physician leadership experience.
• Experience with CDI, coding, and risk adjustment preferred.

Responsibilities

• Provide physician leadership across hospital departments to improve quality and value.
• Partner with CDI and Coding teams to ensure accurate documentation and coding.
• Lead or participate in performance improvement initiatives focused on care quality and safety.
• Support admission, continued-stay, and level-of-care decisions in collaboration with Care Management.
• Educate physicians and staff on documentation practices and regulatory requirements.

Skills

Physician leadership

Cross-functional collaboration

Regulatory knowledge

Clinical documentation

Data-driven decisions

Education

MD/DO degree

Active medical license

Board certification

Job description

City/State: White Plains, New York Department: Office of the CMO Work Shift: Day Work Days: DAYS VARY Scheduled Hours: Hours Vary Hours Per Pay Period: 75 Pay Rate/Range: $250,000 to $500,000

Job Summary The Care Management & Utilization Management Physician Advisor is a physician leader who works across clinical and operational domains to improve the quality, efficiency, coordination, financial integrity, and value of care. The Physician Advisor serves as a trusted liaison among the medical staff, Patient Care Services, Care Management, Utilization Management, Clinical Documentation Integrity (CDI), Coding, Quality and Patient Safety, Transitional Care, Access, Patient Relations, Patient Experience, Finance, Revenue Cycle, and hospital administration. The role extends beyond traditional utilization review and supports hospital-wide clinical operations, accurate clinical documentation and coding, risk adjustment, care progression, physician engagement, performance improvement, high-value care, and complex-case problem solving. The Physician Advisor helps operationalize the organization's Avoid-Adjust-Improve quality strategy. AVOID focuses on preventing inaccurate representation of the patient's clinical condition, including inappropriate principal diagnosis selection, clinical validation concerns, and incorrect cohort assignment. ADJUST focuses on ensuring that clinically supported patient complexity and severity are accurately documented and coded. IMPROVE focuses on measurable improvement in clinical outcomes, safety, reliability, care delivery, and patient experience. The Physician Advisor is expected to integrate all three domains so that organizational performance reflects both the care delivered and the true complexity of the patients served. The Physician Advisor applies clinical judgment, regulatory knowledge, data, and physician leadership to promote documentation and coding that are clinically valid, compliant, and consistent with the patient's actual condition while simultaneously improving care delivery and outcomes.

1. Physician Leadership and Clinical Operations

• Serve as a visible physician leader and clinical-operational partner across hospital departments, translating organizational priorities into physician action and sustainable clinical practice.
• Act as a physician liaison among medical staff, nursing, Care Management, Utilization Management, CDI, Coding, Quality and Patient Safety, Patient Relations, Patient Experience, Transitional Care, Access, Finance, Revenue Cycle, and administration.
• Serve as a physician escalation resource for complex clinical, documentation, utilization, payer, and operational issues requiring cross-disciplinary problem solving, alignment, or de-escalation.
• Identify recurring barriers to high-quality, efficient, accurately represented care and partner with operational leaders to redesign workflows, clarify accountability, and improve execution.
• Support organizational initiatives that promote the right care, at the right time, in the right setting, with appropriate consideration of clinical need, patient goals, expected outcomes, payer requirements, and resource stewardship.

2. Avoid-Adjust-Improve and Enterprise Performance Improvement

• Support the organization's Avoid-Adjust-Improve strategy as an integrated approach to accurate representation of care, recognition of patient complexity, and measurable improvement in clinical outcomes.
• Under AVOID, identify and help prevent inaccurate principal diagnosis selection, clinically unsupported diagnoses, incorrect present-on-admission attribution, or other documentation/coding issues that may place patients in an inappropriate clinical or external-reporting cohort.
• Under ADJUST, work with physicians, CDI, Coding, Quality, and analytics teams to ensure that clinically supported comorbidities, complications, severity, and other risk variables are accurately represented in the medical record and coded data.
• Under IMPROVE, use clinical judgment and performance data to identify opportunities to reduce preventable harm, mortality, complications, avoidable delays, preventable readmissions, unnecessary utilization, and unwarranted variation.
• Lead or participate in multidisciplinary performance improvement initiatives focused on quality, safety, reliability, patient flow, care coordination, clinical documentation, risk-adjusted outcomes, and value.
• Help translate performance signals into actionable interventions for physicians and clinical teams and evaluate whether those interventions produce sustained improvement.

3. Clinical Documentation Integrity, Coding, and Risk Adjustment

• Serve as the physician partner to CDI and Coding teams, providing clinical interpretation, physician-to-physician engagement, and escalation support for complex documentation and coding issues.
• Promote accurate, complete, timely, and clinically supported documentation of diagnoses, procedures, severity of illness, complications, comorbidities, and other elements that affect coding, reimbursement, external reporting, and risk-adjusted outcomes.
• Review selected cases in which documentation, coding, principal diagnosis selection, clinical validation, or risk adjustment may not accurately reflect the patient's condition or course of care.
• Partner with Coding and CDI to improve the accuracy of principal diagnosis selection, present-on-admission status, clinical validation, and clinically appropriate capture of patient complexity while maintaining compliance with applicable coding and regulatory standards.
• Provide physician education and individualized feedback regarding documentation practices, terminology, query response, clinical validation, and the downstream impact of documentation on coded data, risk-adjusted outcomes, payer review, and external performance measurement.
• Collaborate with Quality, analytics, Finance, Revenue Cycle, and clinical leaders to understand how documentation and coded data affect observed-to-expected performance, mortality, complications, readmissions, resource use, reimbursement, and external benchmarking.
• Identify trends in documentation-related or coding-related denials and partner with CDI, Coding, Utilization Management, Revenue Cycle, and medical staff leaders to address recurring causes.
• Support targeted audits and performance reviews when there is concern that documented or coded data do not accurately reflect clinical reality.
• Maintain a compliance-centered approach: documentation and coding recommendations must be clinically valid, evidence-based, and supported by the medical record.

4. Care Management and Utilization Management

• Partner closely with Patient Care Services leadership, the Director of Care Management, and Care Management teams to strengthen care coordination, care progression, and complex-case management.
• Provide physician leadership for admission, continued-stay, level-of-care, and medical-necessity questions in collaboration with Care Management and Utilization Management teams.
• Support timely and appropriate inpatient and observation status decisions in accordance with regulatory and payer requirements.
• Participate in peer-to-peer reviews with payers and provide clinical leadership in medical-necessity denials, appeals, and related escalation processes.
• Participate in Care Management conferences and multidisciplinary case reviews to resolve barriers to discharge, prolonged hospitalization, and other avoidable delays.
• Participate in the Utilization Review Committee and support compliance with applicable Centers for Medicare & Medicaid Services (CMS) Conditions of Participation and payer requirements.

5. Care Progression, Access, and Transitions Across the Continuum

• Partner with clinical teams, Care Management, and the Access team to support appropriate patient placement, transfers, level of care, and efficient progression through the hospital.
• Provide physician input when clinical or operational barriers affect access, placement, transfer, discharge, or transition to the next appropriate site of care.
• Partner with the Transitional Care Team to identify patients and clinical situations in which physician involvement may improve continuity, follow-up, adherence to the care plan, or reduction of preventable readmissions.
• Support multidisciplinary planning for high-risk and complex patients and help resolve clinical barriers that interfere with safe and effective transitions.
• Collaborate across inpatient, ambulatory, home care, post-acute, and community settings as appropriate to strengthen continuity across the care continuum.

6. High-Value Care and Reduction of Unwarranted Variation

• Promote evidence-based, patient-centered, and resource-conscious clinical practice across the medical staff.
• Identify opportunities to reduce unwarranted variation in care, unnecessary testing or treatment, avoidable use of high-cost resources, and care delivered in a suboptimal setting.
• Support development, adoption, and evaluation of clinical pathways, care standards, and other approaches that improve reliability and value.
• Work with physician and operational leaders to address outlier utilization or practice patterns through data, education, peer engagement, and performance improvement rather than solely through administrative review.

7. Patient Relations and Patient Experience

• Collaborate with Patient Relations and Patient Experience teams when physician leadership, clinical interpretation, or escalation is needed to address patient and family concerns.
• Assist in resolving complex concerns involving physician communication, clinical expectations, care coordination, or transitions of care.
• Use themes from patient feedback, complaints, and grievances to identify recurring clinical or operational opportunities and support improvement initiatives.
• Partner with clinical leaders to improve physician communication and patient-centered care while recognizing that overall Patient Experience strategy remains the responsibility of the Patient Experience department.

8. Quality, Safety, and Regulatory Partnership

• Collaborate with Quality and Patient Safety teams in the identification and resolution of selected quality-of-care, safety, reliability, and care‑delivery issues.
• Maintain current knowledge of Medicare, Medicaid, commercial payer, regulatory, documentation, coding, clinical validation, medical‑necessity, and patient‑status requirements relevant to physician advisory work.
• Serve as a physician resource to hospital leadership and clinical teams regarding applicable regulatory and payer requirements.
• Support development and revision of policies and processes related to CDI, coding, risk adjustment, Care Management, Utilization Management, care progression, and other areas within the Physician Advisor's scope.
• Participate in regulatory, payer, audit, or performance reviews as appropriate to the role.

9. Data, Analytics, and Performance Management

• Use clinical, operational, utilization, documentation, coding, risk‑adjustment, quality, patient experience, and financial data to identify performance opportunities and prioritize Physician Advisor interventions.
• Collaborate with analytics and operational teams to develop actionable dashboards and reports that support clinical decision‑making and performance improvement.
• Evaluate observed and expected outcomes, cohort assignment, case mix, documentation trends, denial patterns, utilization, and other performance signals to identify whether opportunity lies in accurate representation, risk adjustment, or actual care delivery.
• Provide physician‑specific or service‑line feedback when appropriate to improve engagement, reduce unwarranted variation, strengthen documentation, and support organizational goals.
• Monitor the impact of interventions and adjust strategies when expected improvement is not achieved.

10. Education, Change Management, and Physician Engagement

• Educate physicians and hospital staff regarding clinical documentation, coding, risk adjustment, Care Management, Utilization Management, patient status, care progression, transitions of care, high‑value care, relevant regulatory changes, and organizational performance priorities.
• Act as a change agent who can influence without relying solely on formal authority and who builds credibility across diverse clinical and administrative teams.
• Facilitate and de‑escalate difficult physician, interdisciplinary, patient, family, payer, documentation, or coding conversations when physician leadership is needed.
• Promote shared accountability and physician ownership of clinical, documentation, utilization, and operational performance.
• Participate in relevant hospital committees and workgroups, including Utilization Review, Care Management, quality, documentation/coding, patient experience, and clinical operations forums.

11. Innovation and Strategic Initiatives

• Provide physician perspective on emerging care models, artificial intelligence and other technologies, operational pilots, and strategic initiatives that may improve quality, access, efficiency, documentation accuracy, care coordination, or value.
• Partner with hospital leadership to evaluate opportunities, define appropriate clinical and operational measures of success, and support adoption of promising new approaches.
• Support strategic partnerships across the health system and care continuum when Physician Advisor expertise can improve implementation or outcomes.
• Maintain awareness of national trends and evolving best practices in the physician advisor profession and identify relevant opportunities for the organization.

Qualifications and Education

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited institution.
• Current, unrestricted medical license in the state of employment.
• Board certification in a medical specialty is required.

Experience

• Minimum of 10 years of clinical practice and progressive physician leadership experience.
• Experience in physician advisory work, CDI, coding, risk adjustment, hospital operations, Care Management, Utilization Management, quality improvement, patient safety, or related clinical leadership is preferred.
• Demonstrated success leading multidisciplinary performance improvement and change‑management initiatives in a healthcare setting is strongly preferred.
• Experience collaborating across medical staff, nursing, CDI, Coding, Care Management, Quality, hospital administration, patient‑facing functions, and payer‑facing functions is preferred.

Preferred Professional Credentials and Engagement

• Care Management Physician Certification (CMPC) and/or American College of Physician Advisors Certification (ACPA‑C) is preferred.
• Certified Physician Executive (CPE) or other relevant physician leadership certification is desirable.
• Active membership or professional engagement in the American College of Physician Advisors (ACPA), the American Physician Leaders Care Management organization, or other relevant professional organizations is preferred.

Skills and Competencies

• Broad understanding of hospital clinical operations and the relationships among documentation, coding, risk adjustment, quality, safety, care progression, utilization, patient experience, transitions of care, and financial stewardship.
• Strong working knowledge of CDI principles, inpatient coding concepts, clinical validation, principal diagnosis selection, present‑on‑admission methodology, and risk‑adjustment concepts relevant to hospital quality and external performance measurement.
• Strong working knowledge of Care Management and Utilization Management principles, CMS requirements, payer practices, and commonly used medical‑necessity criteria, including InterQual and/or MCG.
• Ability to distinguish opportunities related to documentation/coding accuracy, risk adjustment, cohort assignment, and actual clinical performance and to direct improvement efforts accordingly.
• Ability to evaluate clinical and operational problems from a system perspective rather than from a single departmental lens.
• Excellent physician‑to‑physician, interdisciplinary, patient/family, payer, CDI, and coding communication skills.
• Strong conflict‑resolution, facilitation, negotiation, and problem‑solving skills.
• Ability to influence without relying solely on formal authority and to build trust across diverse clinical and administrative teams.
• Analytical ability to interpret clinical, operational, utilization, documentation, coding, risk‑adjusted, quality, patient experience, and financial data and translate findings into action.
• Demonstrated ability to lead performance improvement, change management, and physician engagement initiatives.
• Understanding of high‑value care, care variation, evidence‑based pathways, and resource stewardship.
• Ability to balance patient needs, clinical judgment, quality and safety, coding and regulatory requirements, payer considerations, operational realities, and organizational resources.
• Curiosity and openness to innovation, new care models, and technology‑enabled approaches to clinical operations, documentation, and performance improvement.

Professional Development Expectations

• Maintain current knowledge of regulatory, payer, CDI, coding, risk‑adjustment, quality, care management, utilization management, patient experience, and physician advisor best practices through continuing education and professional development.
• Engagement with national physician advisor organizations, including the American College of Physician Advisors (ACPA), is encouraged to support ongoing professional development, benchmarking, and awareness of evolving physician advisor practice.

Work Environment

• Primarily a hospital‑based physician leadership role requiring regular engagement with physicians, CDI, Coding, Care Management, clinical teams, patients and families, and hospital leadership.
• Some administrative responsibilities may be performed remotely as appropriate.
• May require occasional travel to affiliated facilities or for professional development.

Reports To

Chief Quality Officer (CQO) or designated hospital leader.

Other Responsibilities

Performs other duties and physician leadership responsibilities as assigned and consistent with the scope of the position.

Key Performance Indicators (KPIs)

1. Clinical Documentation, Coding, and Risk Adjustment

   • Improvement in the accuracy and completeness of clinically supported documentation and coded data in targeted populations or service lines.
   • Improvement in principal diagnosis accuracy, present‑on‑admission accuracy, clinical validation, or other targeted audit measures.
   • Reduction in preventable documentation‑related, coding‑related, and clinical‑validation denials.
   • Improvement in clinically appropriate capture of patient complexity and severity when supported by the medical record.
   • Improved alignment between clinical reality, documented conditions, coded data, risk‑adjusted expected outcomes, and external performance cohorts.

2. Clinical Operations and Care Progression

   • Improvement in average and/or observed‑to‑expected length of stay, as applicable.
   • Reduction in avoidable days, prolonged‑stay cases, and recurring clinical or operational barriers to progression of care.
   • Timely and effective resolution of complex cases escalated to the Physician Advisor.
   • Improvement in selected patient‑flow, access, or care‑progression measures targeted through Physician Advisor intervention.

3. Utilization Management and Medical Necessity

   • Reduction in avoidable medical‑necessity and patient‑status denials.
   • Peer‑to‑peer review completion and success/overturn rate.
   • Timeliness and appropriateness of inpatient/observation status determinations.
   • Improvement in identified utilization outliers or recurring payer issues targeted through Physician Advisor intervention.

4. Quality, Safety, and Avoid‑Adjust‑Improve

   • Demonstrated improvement in selected quality, safety, reliability, mortality, complication, clinical variation, or high‑value care initiatives for which the Physician Advisor has defined responsibility.
   • Demonstrated ability to distinguish and address performance opportunities attributable to inaccurate cohorting/documentation (Avoid), incomplete capture of clinically supported patient complexity (Adjust), or actual clinical outcomes and care delivery (Improve).
   • Successful completion and sustained impact of assigned Avoid‑Adjust‑Improve initiatives.
   • Improved adoption of targeted evidence‑based pathways, care standards, or resource‑stewardship initiatives.

5. Transitions of Care and Readmissions

   • Improvement in 30‑day readmission performance for targeted populations.
   • Successful connection of eligible high‑risk patients to Transitional Care services.
   • Improvement in completion of targeted post‑discharge follow‑up or transition interventions.

6. Patient Relations and Patient Experience

   • Timely physician review and resolution of escalated patient or family concerns requiring clinical leadership.
   • Improvement in recurring themes related to physician communication, care coordination, or transitions of care.
   • Demonstrated contribution to improvement initiatives arising from Patient Relations and Patient Experience feedback.

7. Physician Engagement and Change Management

   • Physician participation in and adoption of targeted documentation, coding, risk‑adjustment, clinical, operational, Care Management, Utilization Management, or high‑value care initiatives.
   • Effective physician education and feedback demonstrated by measurable changes in targeted documentation, practice, or process measures.
   • Completion and demonstrated impact of assigned performance improvement or strategic initiatives.

8. Regulatory and Financial Stewardship

   • Compliance with applicable documentation, coding, utilization‑management, and physician advisor regulatory requirements.
   • Reduction in preventable denial‑related financial loss within areas influenced by the Physician Advisor.
   • Documented clinical, operational, quality, or financial benefit from targeted Physician Advisor initiatives.

Equal Opportunity Employer Statement

Our organization is committed to creating a diverse and inclusive workplace. We provide equal employment opportunities to all employees and applicants without regard to race, color, religion, sex, gender, national origin, age, disability, veteran status, or any other status protected by applicable law. Compensation is based on years of relevant experience, required licensure, education and applicable qualifications. White Plains Hospital Medical Center is an equal employment opportunity employer. White Plains Hospital Medical Center will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.

White Plains Hospital is a proud member of the Montefiore Health System, serving as its tertiary hub of advanced care in the Hudson Valley. The Hospital is a 292‑bed not‑for‑profit health care organization with the primary mission of providing exceptional acute and preventive medical care to all people who live in, work in or visit Westchester County and its surrounding areas. White Plains Hospital has outpatient medical facilities across Westchester, including multispecialty practices in Armonk, Hawthorne, Larchmont, New Rochelle, Rye Brook, Scarsdale, Somers, Yonkers and Yorktown Heights; and Scarsdale Medical Group locations in Harrison and Scarsdale. The Hospital is fully accredited by the Joint Commission, and in 2025 received another 5-star rating from the Centers for Medicare & Medicaid Services (CMS) — the highest distinction offered by the federal agency – for the fourth consecutive year. In addition, the Hospital received its third Magnet® designation from the American Nurses Credentialing Center (ANCC), a distinction held by only two percent of hospitals in the country. White Plains Hospital has consistently received the Outstanding Patient Experience Award from Healthgrades®, and in 2025 was awarded an “A” Safety Grade from the Leapfrog Group for the 14th consecutive time.