Physician Advisor: Optimize Care & Denial Resolution

ACPM; San Antonio (TX); On-site; USD 140,000 - 210,000; Full time

Job summary

CHRISTUS Health in Irving, TX seeks a physician advisor reporting to the System Medical Director for Physician Advisory services. The role supports utilization review, care management, and denial management with a focus on medical necessity and appropriate resource use.

The successful candidate will conduct reviews, engage in peer-to-peer discussions with payers, and guide care teams on level of care and discharge planning, while maintaining regulatory compliance and quality outcomes.

Qualifications

• Knowledge of CMS/commercial insurance rules and regulations regarding medical necessity and appropriate use of resources.
• Strong organizational skills with attention to detail.
• Excellent analytical and problem-solving skills.
• Effective verbal and written communication skills.
• Proven capability to communicate to develop positive relationships with medical staff, physicians, nurses, care managers and others.
• Proficient EMR and computer software skills.
• Ability to understand, comply and advance CHRISTUS Health strategic priorities, commitments, and values.

Responsibilities

• Conduct status reviews and secondary case reviews to assess medical necessity, level of care, and provide recommendations to attending providers.
• Conduct peer-to-peer consults and coordinate discussions with payer medical directors to resolve medical necessity issues before claims submission.
• Meet health system objectives for quality care and efficient resource utilization while complying with regulations.
• Collaborate with care management and healthcare teams on elective cases and care progression decisions.
• Participate in case denial meetings to identify opportunities and reduce denials.
• Interact with medical staff and payer directors to discuss patient access and alternative care levels.
• Serve as consultant to the CDI team for query facilitation.
• Assist transfer center with challenging case reviews.
• Prepare analyses of short-term projects to explain claims and opportunities to leadership.
• Support system leadership in reducing avoidable length of stay and improving throughput.
• Ensure compliance with state and federal regulations.

Skills

CMS/insurance rules knowledge

Organizational skills

Analytical/problem-solving

Verbal/written communication

Interpersonal relationships with staff

EMR/computer skills

Understanding CHRISTUS priorities

Education

MD/DO degree

Board certification in clinical specialty

Job description

CHRISTUS Health in Irving, TX seeks a physician advisor reporting to the System Medical Director for Physician Advisory services. The role supports utilization review, care management, and denial management with a focus on medical necessity and appropriate resource use.

The successful candidate will conduct reviews, engage in peer-to-peer discussions with payers, and guide care teams on level of care and discharge planning, while maintaining regulatory compliance and quality outcomes.