Physician Advisor (Clinical Assistant Professor, HS)

Downstate; New York (NY); Hybrid; USD 180,000 - 240,000; Full time

Job summary

Downstate is seeking a Physician Advisor to optimize healthcare delivery by guiding medical necessity decisions, utilization management, and quality initiatives. In this full-time role, you will partner with clinicians, case managers, and CDI to improve documentation, coding alignment, and outcomes.

You will lead policy development, oversee the Utilization Management Committee, and monitor performance indicators to balance patient care with cost efficiency.

Qualifications

• Experience in utilization management and determining medical necessity.
• Ability to educate and train healthcare professionals on documentation and compliance.
• Leadership in policy development and committee oversight.

Responsibilities

• Review medical records to assess service appropriateness and regulatory compliance.
• Evaluate procedures and hospital admissions based on criteria.
• Collaborate with case managers and providers to optimize discharge planning and resource use.
• Lead denial management and educate on documentation best practices to reduce denials.
• Educate staff on utilization management principles and regulatory requirements.
• Coordinate with CDI to improve documentation quality and risk-adjusted measures.
• Work with physicians, nurses, and admins to improve communication and care coordination.
• Contribute to updating utilization management policies and protocols.
• Lead the Utilization Management Committee and monitor KPIs related to care and costs.
• Perform other duties as assigned by the CMO.

Skills

Utilization management

Medical necessity assessment

Regulatory compliance

Education and training

Performance monitoring

Interdisciplinary collaboration

Tools

ICD-10 coding

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