Physician Advisor - Utilization & Compliance

St. Joseph's Health; Paterson (NJ); On-site; USD 140,000 - 200,000; Full time

Job summary

St. Joseph's Health seeks a Physician Advisor to provide clinical expertise in utilization management, medical necessity reviews, and denials management. You will collaborate with physicians, Care Management, Social Work, hospital leadership, and payers to ensure appropriate care levels and regulatory compliance.

The role supports throughput and timely transitions of care, with daily hours Monday–Friday and occasional extra coverage for time-sensitive issues.

Qualifications

• Strong clinical judgment, analytical, communication, and problem-solving skills.
• Experience in utilization management, payer communications, and clinical guidance.

Responsibilities

• Perform admission, observation, continued-stay, readmission and pre-post-bill reviews.
• Evaluate medical necessity and patient status per CMS and payer criteria.
• Support denials management, medical necessity appeals, and payer communications.
• Participate in utilization management, observation, length-of-stay, and escalation activities.
• Identify barriers to discharge and collaborate to improve throughput.
• Provide physician education and consultation on medical necessity and documentation.
• Participate in Utilization Management and quality improvement committees.
• Support CMS, NJDOH, Joint Commission, and payer regulatory compliance.
• Provide clinical guidance and education to medical staff and leadership as needed.

Skills

Clinical judgment

Analytical

Communication

Problem-solving

Education

Medical degree from an accredited medical school

Job description

St. Joseph's Health seeks a Physician Advisor to provide clinical expertise in utilization management, medical necessity reviews, and denials management. You will collaborate with physicians, Care Management, Social Work, hospital leadership, and payers to ensure appropriate care levels and regulatory compliance.

The role supports throughput and timely transitions of care, with daily hours Monday–Friday and occasional extra coverage for time-sensitive issues.