Physician Advisor - Utilization & Denials Leader

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

Job summary

Riverside Healthcare seeks a detail oriented Physician Advisor to join our inpatient team full time. This role is a key clinical and operational leader, supporting effective utilization of healthcare services and ensuring compliance with payer and regulatory requirements.

The Physician Advisor provides expertise in medical necessity, documentation, care progression, and denial management, working with Care Management, Utilization Review, Revenue Cycle and hospital leadership.

Qualifications

• MD or DO with IL medical license.
• Minimum 5 years clinical hospital experience.
• Experience in utilization management and hospital operations preferred.

Responsibilities

• Make recommendations on level of care (initial and secondary) per case management.
• Suggest documentation improvements to reflect patient status and regulatory requirements.
• Collaborate with providers to clarify rationale for services and support appropriate reimbursement.
• Participate in denials management and lead denial reduction efforts.
• Perform peer-to-peer appeals and draft letters for third-party denials when needed.
• Apply 2-midnight rule to Medicare reviews and ensure compliance with payer rules.
• Mentor and educate staff on utilization review processes.

Skills

Utilization management

Denials management

Peer to peer appeals

Care team collaboration

Education

MD/DO

IL medical license

Tools

InterQual/MCG

ABQAURP HCQM

ACPA-C

Job description

Riverside Healthcare seeks a detail oriented Physician Advisor to join our inpatient team full time. This role is a key clinical and operational leader, supporting effective utilization of healthcare services and ensuring compliance with payer and regulatory requirements.

The Physician Advisor provides expertise in medical necessity, documentation, care progression, and denial management, working with Care Management, Utilization Review, Revenue Cycle and hospital leadership.