Physician Advisor: Medical Necessity & Denials Lead

AtlantiCare Health System; New Jersey; On-site; USD 388,000 - 459,000; Full time

Benefits offered by this job

Generous Paid Time Off (PTO)

Medical, Prescription Drug, Dental, &

Retirement Plans with employer 100%

Short-Term & Long-Term Disability

Life & Accidental Death & Dismembermt

Job summary

AtlantiCare Health System in Atlantic City, NJ is seeking a Physician Advisor to partner with medical staff and care teams to ensure medically necessary, high-quality, efficient care. You will provide physician-to-physician guidance on patient status, level of care, and documentation while addressing denials and payer requirements.

You will lead CDI and coding collaboration, conduct reviews, educate clinicians, and help optimize QoS metrics, length of stay, and revenue cycle performance.

Qualifications

• MD or DO from an accredited medical school.
• Current, unrestricted New Jersey medical license and eligibility for AtlantiCare medical staff membership.
• Board certification in a clinical specialty; certification in health care quality, utilization management, or physician advising preferred.
• Minimum five years of recent clinical practice experience; acute-care experience preferred.
• Working knowledge of utilization management, CDI, coding and reimbursement, medical necessity, level-of-care criteria, denials and appeals.
• Experience with evidence-based criteria such as MCG and proficiency with electronic health records and related clinical systems.
• Strong clinical judgment, analytical ability, communication, physician engagement, education, collaboration, organization, and change-management skills.

Responsibilities

• Conducts concurrent and retrospective medical record reviews to evaluate medical necessity, patient status, level of care, continued stay, care progression, clinical validation, and documentation completeness.
• Leads denial prevention and appeal strategy by providing clinical leadership for denial prevention, payer disputes, peer-to-peer reviews, and appeals.
• Analyze denial trends and develop strategies to reduce avoidable denials and protect appropriate reimbursement.
• Provides timely physician-to-physician consultation to attending physicians, ED clinicians, case managers, CDI specialists, coding professionals, and other care team.
• Physician-led CDI/clinical validation by providing physician leadership for clinical documentation integrity and clinical validation initiatives.
• Review DRG assignment and SOI/ROM trends to improve documentation accuracy and capture patient complexity; develop targeted physician education on medical necessity, UM, CDI, coding, and regulatory changes.

Skills

Clinical judgment

Analytical ability

Communication

Physician engagement

Education

Collaboration

Organization

Change management

Education

MD/DO degree

Medical license in NJ

Board certification in clinical specialty

Tools

Electronic Health Records proficiency

Job description

AtlantiCare Health System in Atlantic City, NJ is seeking a Physician Advisor to partner with medical staff and care teams to ensure medically necessary, high-quality, efficient care. You will provide physician-to-physician guidance on patient status, level of care, and documentation while addressing denials and payer requirements.

You will lead CDI and coding collaboration, conduct reviews, educate clinicians, and help optimize QoS metrics, length of stay, and revenue cycle performance.