Physician Advisor

Riverside Healthcare; Kankakee (IL); On-site; USD 131,000 - 194,000; Full time

Job summary

Riverside Medical Group in Kankakee, IL is seeking a Physician Advisor to lead utilization review for inpatient services on a full-time basis. The role focuses on medical necessity, documentation, level of care recommendations, and denial management within the care management and revenue cycle teams.

Ideal candidates have 5+ years hospital-based clinical experience, an MD or DO, and an Illinois license. Preference for certifications in quality or physician advisory roles and familiarity with

Qualifications

• MD or DO with unrestricted Illinois medical license.
• Minimum 5 years of hospital-based clinical experience.
• Experience in utilization management and denial prevention.
• Familiarity with InterQual, MCG or equivalent criteria.
• Physician advisor responsibilities incl. documentation and level of care decisions.

Responsibilities

• Make level of care recommendations for initial and secondary reviews.
• Improve documentation to reflect clinical status and regulatory requirements.
• Collaborate with care management to reduce denials and enhance reimbursement.
• Lead and mentor staff on utilization review and payer rules.
• Perform peer-to-peer appeals and draft denial letters as needed.
• Apply 2-midnight rule and stay current with CMS/util payer rules.
• Support LOS strategies and participate in denial management.

Skills

Utilization management

Documentation improvement

Denial management

InterQual/MCG criteria

Peer to peer appeals

Education

MD or DO

Illinois medical license

Palliative Care Fellowship (preferred)

ABQAURP HCQM certification (preferred)

ACPA-C certification (preferred)

Tools

InterQual

MCG criteria

Job description

Overview

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.

Essential Duties

• 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.
• 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.
• Review for daily level of care recommendations on cases placed in Observation
• Participate in the denials management process
• Be a leader in optimizing 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
• Maintain compliance with Medicare rules as it applies to level of care recommendations
• Stay current on changes in payer rules including CMS rules as it pertains to utilization review
• Recommend and request additional and more complete medical record documentation from providers to support placement status or medical necessity
• Understand and use InterQual, MCG and/or other appropriate criteria
• Apply medical expertise to assist with appropriate billing for services
• Provide feedback on payer denial patterns where appropriate
• Aid 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

Required Education/Licensure

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

Required Experience

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

Preferred Education/Licensure

• 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)

Location

Riverside Medical Group

350 N. Wall St. Kankakee, IL

Employee Health Requirements

• 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.

Activity/Lifting Requirements

• 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: 5lbs frequent
• Fine Manipulation: Moving charts, written documentation.
• Repetitive use of foot or feet in operating machine control: None

Environmental Factors & Special Hazards

• 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

Pay Range

USD $95.38 - USD $141.06 /Hr