Physician Advisor (Clinical Assistant Professor, HS)

SUNY Downstate; New York (NY); On-site; USD 130,000 - 180,000; Full time

Job summary

SUNY Downstate Health Sciences University seeks a Physician Advisor to optimize healthcare delivery through guidance on medical necessity, utilization management, and quality improvement initiatives.

The role collaborates with physicians, case managers, CDI, and other stakeholders to ensure compliant, cost-effective care and strong documentation practices. It includes leading the Utilization Management Committee and providing education to clinicians.

Qualifications

• Experience in utilization management and regulatory compliance.
• Knowledge of ICD-10 coding and medical necessity criteria.
• Strong communication and leadership skills for physician education.

Responsibilities

• Perform Utilization Review of medical records to assess appropriateness and regulatory compliance.
• Determine medical necessity for procedures, treatments, and admissions, including inpatient vs. observation.
• Lead Discharge Planning efforts with case managers to optimize length of stay and resource use.
• Oversee Denial Management by analyzing trends and guiding appeals with clinical justification.
• Provide Education and Training to staff on utilization management principles and documentation requirements.
• Collaborate with CDI to improve physician documentation, utilization, and risk-adjusted quality measures.
• Foster intradisciplinary collaboration among physicians, nurses, and administrators to coordinate care.
• Contribute to policy development and revision of utilization management procedures.
• Lead the Utilization Management Committee to monitor KPIs related to care quality and cost.
• Engage in other duties as assigned by the CMO, with clinical duties up to 25% of the role.

Skills

Utilization Review

Medical Necessity

Discharge Planning

Denial Management

Education & Training

CDI Collaboration

Interdisciplinary Collaboration

Policy Development

Leadership & Oversight

Performance Monitoring

Job description

The Physician Advisor plays a critical role in optimizing healthcare delivery by providing guidance on medical necessity, utilization management, and quality improvement initiatives. They collaborate with healthcare teams to ensure compliance with regulatory standards and promote cost-effective care delivery. This is a full-time position reports to the Chief Medical Officer. Candidates can inquire about part-time availability.

Key Functional Duties:

• Utilization Review: Review medical records and documentation to assess the appropriateness of services rendered and ensure compliance with regulatory guidelines.

• Medical Necessity Determination: Evaluate the medical necessity of procedures, treatments, and hospital admissions/level of care (Inpatient vs. observation) based on established criteria and guidelines.

• Optimizing Discharge Planning: Collaborate with case managers, Social works, and healthcare providers to develop care plans that meet patients' clinical needs while optimizing resource utilization to improve Length of Stay. Work with the other stakeholders to optimize IDR

• Denial Management: Lead the denial appeal process to optimize the resolution of insurance denials by providing clinical expertise and supporting appeals processes. The Physician advisor will identify trends in denial cases, perform root cause analysis, and develop actionable plans to prevent future denials. This includes providing targeted physician education on documentation best practices and ensuring alignment with appropriate ICD-10 coding and medical necessity criteria

• Education and Training: Provide education and training to healthcare professionals on utilization management principles, documentation requirements, and regulatory compliance.

• CDI: Collaborate with CDI to ensure appropriate physician documentation with a goal to improve utilization, CMI, and risk adjusted quality measures

• Intradisciplinary Collaboration: Work closely with physicians, nurses, administrators, and other stakeholders to promote effective communication and coordination of care.

• Policy Development: Contribute to the development and revision of utilization management policies, protocols, and procedures.

• Leading the Utilization Management Committee

• Performance Monitoring: Monitor and evaluate key performance indicators related to utilization management, quality of care, and financial outcomes.

• Clinical duties: up to 25% of the position

• Perform other duties as assigned by the CMO