Physician Advisor: Utilization & Denials Leader

Riverside Healthcare; Kankakee (IL); On-site; USD 131,000 - 194,000; Full time

Job summary

Riverside Medical Group in Kankakee, IL is seeking a Physician Advisor to lead utilization review for inpatient services on a full-time basis. The role focuses on medical necessity, documentation, level of care recommendations, and denial management within the care management and revenue cycle teams.

Ideal candidates have 5+ years hospital-based clinical experience, an MD or DO, and an Illinois license. Preference for certifications in quality or physician advisory roles and familiarity with

Qualifications

• MD or DO with unrestricted Illinois medical license.
• Minimum 5 years of hospital-based clinical experience.
• Experience in utilization management and denial prevention.
• Familiarity with InterQual, MCG or equivalent criteria.
• Physician advisor responsibilities incl. documentation and level of care decisions.

Responsibilities

• Make level of care recommendations for initial and secondary reviews.
• Improve documentation to reflect clinical status and regulatory requirements.
• Collaborate with care management to reduce denials and enhance reimbursement.
• Lead and mentor staff on utilization review and payer rules.
• Perform peer-to-peer appeals and draft denial letters as needed.
• Apply 2-midnight rule and stay current with CMS/util payer rules.
• Support LOS strategies and participate in denial management.

Skills

Utilization management

Documentation improvement

Denial management

InterQual/MCG criteria

Peer to peer appeals

Education

MD or DO

Illinois medical license

Palliative Care Fellowship (preferred)

ABQAURP HCQM certification (preferred)

ACPA-C certification (preferred)

Tools

InterQual

MCG criteria

Job description

Riverside Medical Group in Kankakee, IL is seeking a Physician Advisor to lead utilization review for inpatient services on a full-time basis. The role focuses on medical necessity, documentation, level of care recommendations, and denial management within the care management and revenue cycle teams.

Ideal candidates have 5+ years hospital-based clinical experience, an MD or DO, and an Illinois license. Preference for certifications in quality or physician advisory roles and familiarity with