Physician Advisor: Utilization Management & Denials

St. Joseph's Health; Paterson (NJ); On-site; USD 160,000 - 210,000; Full time

Job summary

St. Joseph's Health in New Jersey is seeking a Physician Advisor to provide clinical expertise for utilization management, medical necessity reviews, and denials management. You will collaborate with physicians, Care Management, and leadership to ensure appropriate level of care and timely transitions of care.

The role supports compliance with CMS and payer requirements and offers opportunities to educate clinical staff while improving throughput and patient outcomes.

Qualifications

• Graduate of an accredited medical school with active clinical experience.
• Minimum five years of recent clinical practice in a hospital setting.
• Strong clinical judgment, analytical mindset, and effective communication.

Responsibilities

• Perform admission, observation, continued-stay, second-level, short-stay, readmission, and pre-post-bill reviews.
• Evaluate medical necessity and patient status per CMS Two-Midnight Rule and payer criteria.
• Support denials management, medical necessity appeals, and payer communications.
• Participate in utilization management, observation, length-of-stay, and escalation activities.
• Identify discharge barriers and collaborate with Care Management to improve throughput.
• Provide physician education and consultation on medical necessity, documentation, and level of care.
• Participate in Utilization Management and quality improvement committees.
• Ensure compliance with CMS, NJDOH, Joint Commission, and payer requirements.
• Offer clinical guidance and education to medical staff and hospital leadership.

Skills

Clinical judgment

Analytical skills

Communication skills

Problem-solving

Denials & appeals experience

CMS regulations knowledge

Education

Graduate of an accredited medical school

Minimum five years of clinical practice

Job description

St. Joseph's Health in New Jersey is seeking a Physician Advisor to provide clinical expertise for utilization management, medical necessity reviews, and denials management. You will collaborate with physicians, Care Management, and leadership to ensure appropriate level of care and timely transitions of care.

The role supports compliance with CMS and payer requirements and offers opportunities to educate clinical staff while improving throughput and patient outcomes.