Physician Advisor- Utilization Management & Clinical Documentation Integrity- ONSITE

Trinity Health Mid-Atlantic; Athens (GA); On-site; USD 180,000 - 260,000; Full time

Job summary

Trinity Health in Georgia is seeking an experienced Physician Advisor to optimize clinical documentation, utilization management, and hospital throughput. You will educate clinicians, guide case reviews, and collaborate with care teams to improve patient flow while ensuring compliance with CMS rules.

This full-time, 1099 position offers leadership opportunities and ongoing engagement with residents. Ideal candidates hold an MD/DO, board certification, and hospital-based care experience.

Qualifications

• Required MD or DO degree from an accredited institution.
• Board Certified in a recognized medical specialty.
• Active unrestricted medical license to practice medicine in the state of Georgia.
• Minimum of 5 years clinical practice experience.
• Experience working in hospital-based care.
• Demonstrated leadership, people management, and team building skills.
• Excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.
• Ability to develop and implement strategic clinical plans.
• Excellent oral and written communication skills.
• Ability to interact effectively with key internal and external constituents using collaboration and customer service skills.

Responsibilities

• Partner with CDI specialists to improve clinical documentation accuracy and completeness.
• Provide physician-to-physician education on documentation requirements.
• Assist with case mix index (CMI) improvement initiatives.
• Review complex cases for documentation opportunities reflecting patient acuity.
• Provide physician guidance for medical necessity determinations.
• Review cases for appropriate inpatient vs observation status.
• Support case management staff with complex utilization reviews.
• Conduct peer-to-peer reviews with payers.
• Collaborate with care management teams to address barriers to timely discharge.
• Work with clinical teams to reduce avoidable length of stay and excess days.
• Participate in daily multidisciplinary rounds to address throughput challenges and delayed discharges.
• Teach residents about the role of the Physician Advisor and KPI alignment.
• Review payer denials related to medical necessity and level of care.
• Write and support clinical appeal letters and participate in denials management.
• Educate medical staff on documentation, utilization management, and efficient care delivery.
• Present findings at Medical staff meetings, service line meetings, and quality committees.

Skills

Leadership

Communication

Time management

Collaboration

Negotiation

Conflict management

Independence

Strategic planning

Education

MD or DO degree

Tools

EMR systems

Job description

Employment Type

Full time Shift: Description: THIS IS A 1099 POSITION

Key Responsibilities and Essential Functions

Clinical Documentation & Case Mix

• Partner with CDI specialists to improve clinical documentation accuracy and completeness
• Provide physician-to-physician education on documentation requirements related to: Severity of illness Risk of mortality CC/MCC capture DRG assignment
• Assist with case mix index (CMI) improvement initiatives
• Review complex cases for documentation opportunities that accurately reflect patient acuity

Utilization Management & Length of Stay Optimization

• Provide physician guidance for medical necessity determinations
• Review cases for appropriate inpatient vs observation status
• Support case management staff with complex utilization reviews
• Conduct peer-to-peer reviews with payers
• Collaborate with care management teams to identify and address barriers to timely discharge
• Work with clinical teams to reduce avoidable length of stay and excess days
• Participate in daily multidisciplinary rounds and discussions to address throughput challenges and delayed discharges
• Work with our Internal Medicine Residents to teach them what a Physician Advisor does and how to align and balance patient care with the KPI’s the Physician Advisor works on to improve.

Opportunity Days Reduction

• Review cases with extended length of stay to identify clinical, operational, or documentation barriers contributing to opportunity days
• Partner with case management, nursing leadership, and service line leaders to address drivers of avoidable hospital days
• Provide physician leadership in resolving delays related to: Clinical decision-making Documentation gaps Discharge readiness Specialist consultation delays
• Support hospital initiatives aimed at improving patient flow and capacity management

Denials Prevention & Appeals

• Review payer denials related to: Medical necessity Level of care DRG downgrades
• Write and support clinical appeal letters
• Participate in denials management strategy
• Identify systemic issues contributing to denials and implement improvement strategies

Physician Engagement & Education

• Provide education to medical staff on documentation, utilization management, and efficient care delivery
• Present findings at: Medical staff meetings Service line meetings Quality committees
• Serve as a physician champion for documentation improvement, medical necessity compliance, and hospital throughput

Quality & Compliance

• Ensure hospital practices align with: CMS Conditions of Participation Medicare documentation rules Two-midnight rule Utilization review regulations
• Partner with Quality and Compliance departments to ensure regulatory alignment

Data Review & Performance Improvement

• Monitor, analyze, and actively strive to improve key hospital performance metrics including, but not limited to: Case Mix Index (CMI) Length of Stay Index (Observed vs Expected LOS and %GMLOS) Opportunity Days Observation rates Medical necessity denial rates CC/MCC capture rate
• Identify opportunities for clinical, operational, and documentation improvement

Qualifications

• Required MD or DO degree from an accredited institution
• Board Certified in a recognized medical specialty
• Active unrestricted medical license to practice medicine in the state of Georgia.
• Minimum of 5 years clinical practice experience
• Experience working in hospital-based care
• Demonstrated leadership, people management, and team building skills
• Must have excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.
• Ability to develop and implement strategic clinical plans
• Excellent oral and written communication skills
• Ability to interact effectively with key internal and external constituents using collaboration and customer service skills that promote excellence in the patient experience.
• Customer service orientation
• Demonstrated confidence, initiative, and integrity in work practices
• Goal-directed and well organized
• High level of dependability and accuracy
• Ability to work independently
• Strong negotiation and persuasion skills
• Adept at conflict management
• Ability to function within a stressful environment
• Strong computer skills and working knowledge of EMR’s
• A broad knowledge base of health care delivery and case management within a managed care environment
• Comprehensive knowledge of Utilization Review, levels of care, and observation status

Preferred

• Prior experience as a Physician Advisor, Medical Director, or Utilization Review physician
• Experience with: Clinical Documentation Integrity (CDI) Utilization Management Revenue cycle operations Denials management Length of stay improvement initiatives
• Knowledge of: MS-DRG reimbursement Case Mix Index CMS inpatient admission criteria
• Certification such as: CHCQM-PHYADV (Certified Physician Advisor)
• Additional advanced degree (MBA, MPH, MMM, etc)
• Awareness of healthcare reimbursement systems (HMO, PPO, PPS,CMS)

Our Commitment

Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care.

Equal Opportunity Employer

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

About Trinity Health

Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services.

Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs.

For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.