Physician Advisor - Medical Necessity & UR Lead

Sentara Health Plans; Virginia Beach (VA); On-site; USD 180,000 - 260,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

Tuition assistance – Guild Education

Paid time off & family leave

401k/403B with employer match

Job summary

Sentara Virginia Beach General Hospital is seeking a Physician Advisor to conduct timely medical necessity reviews and support denials management within the centralized UR process. The role emphasizes on-site presence and collaboration with medical staff and hospital leadership to ensure compliant hospital status and accurate billing.

Requirements include an active Virginia medical license, board certification in a medical specialty, and completion of an accredited residency.

Qualifications

• MD or DO degree from an accredited medical school (Required).
• Completion of an accredited residency training program (Required).
• Active and unrestricted Virginia medical license (Required).
• Board certification in specialty at time of hire (Required).
• CMS regulatory guidance and UR knowledge (Required).
• Experience with hospital billing/coding processes and DRG assignments (Required).
• Familiarity with MCG/Interqual criteria and professional judgment (Required).
• Strong interpersonal and communication skills (Required).
• Ability to work on-site and collaborate with leadership and medical staff (Required).

Responsibilities

• Perform timely and compliant medical necessity reviews and document case specifics for regulatory compliance.
• Facilitate denials management including peer-to-peer discussions and appeals letters.
• Collaborate with hospital leadership, medical staff, and ICM to support system initiatives.
• Attend Hospital UM committees and participate in educational sessions for staff and leadership.

Skills

Medical license

Board certification

CMS regulatory knowledge

UR knowledge

Communication skills

Interdisciplinary collaboration

Education

MD or DO degree

Accredited residency

Tools

EMR proficiency

Job description

Sentara Virginia Beach General Hospital is seeking a Physician Advisor to conduct timely medical necessity reviews and support denials management within the centralized UR process. The role emphasizes on-site presence and collaboration with medical staff and hospital leadership to ensure compliant hospital status and accurate billing.

Requirements include an active Virginia medical license, board certification in a medical specialty, and completion of an accredited residency.