Onsite Physician Advisor: Utilization & Denial Management

CHRISTUS St. Vincent; San Antonio (TX); On-site; USD 190,000 - 230,000; Full time

Job summary

CHRISTUS St. Vincent seeks a Physician Advisor to support medical necessity determinations, level of care decisions, and resource stewardship across the hospital system.

The role partners with utilization review, care management, CDI, and transfer centers to optimize patient care progression and reduce inpatient denials. Board certification in HCQM is preferred and travel may be required.

Qualifications

• MD or DO degree from an accredited medical school.
• 5 years of experience in the clinical setting.
• 2 years in a physician advisor role or equivalent.
• 2 years in leadership and/or management roles.
• Board-certified in a clinical specialty.
• Board certification in HCQM (ABQMURP) preferred.

Responsibilities

• Conduct status reviews to assess medical necessity and level of care, with recommendations to attending providers.
• Perform peer-to-peer consultations with payer medical directors to resolve denial issues before claims submission.
• Support quality and regulatory objectives while optimizing resource utilization.
• Collaborate with care management and healthcare teams on elective cases and care progression.
• Participate in denial meetings to identify opportunities and reduce inappropriate denials.
• Engage with medical staff and payer directors to discuss patient access and alternative care levels.
• Serve as consultant to the CDI team for query facilitation and to the transfer center for complex reviews.
• Develop and present analyses of short-term projects to leadership on claims and opportunities.
• Assist the System Medical Director in reducing avoidable length of stay and improving throughput.
• Support compliance with state and federal regulations.

Skills

CMS rules

Organizational skills

Analytical skills

Communication skills

Relationship building

EMR proficiency

Strategic alignment

Education

MD/DO degree

Board-certified in a clinical specialty

HCQM certification preferred

Job description

CHRISTUS St. Vincent seeks a Physician Advisor to support medical necessity determinations, level of care decisions, and resource stewardship across the hospital system.

The role partners with utilization review, care management, CDI, and transfer centers to optimize patient care progression and reduce inpatient denials. Board certification in HCQM is preferred and travel may be required.