Physician Advisor: Utilization & Quality Improvement

Downstate; New York (NY); Hybrid; USD 180,000 - 240,000; Full time

Job summary

Downstate is seeking a Physician Advisor to optimize healthcare delivery by guiding medical necessity decisions, utilization management, and quality initiatives. In this full-time role, you will partner with clinicians, case managers, and CDI to improve documentation, coding alignment, and outcomes.

You will lead policy development, oversee the Utilization Management Committee, and monitor performance indicators to balance patient care with cost efficiency.

Qualifications

• Experience in utilization management and determining medical necessity.
• Ability to educate and train healthcare professionals on documentation and compliance.
• Leadership in policy development and committee oversight.

Responsibilities

• Review medical records to assess service appropriateness and regulatory compliance.
• Evaluate procedures and hospital admissions based on criteria.
• Collaborate with case managers and providers to optimize discharge planning and resource use.
• Lead denial management and educate on documentation best practices to reduce denials.
• Educate staff on utilization management principles and regulatory requirements.
• Coordinate with CDI to improve documentation quality and risk-adjusted measures.
• Work with physicians, nurses, and admins to improve communication and care coordination.
• Contribute to updating utilization management policies and protocols.
• Lead the Utilization Management Committee and monitor KPIs related to care and costs.
• Perform other duties as assigned by the CMO.

Skills

Utilization management

Medical necessity assessment

Regulatory compliance

Education and training

Performance monitoring

Interdisciplinary collaboration

Tools

ICD-10 coding

Job description

Downstate is seeking a Physician Advisor to optimize healthcare delivery by guiding medical necessity decisions, utilization management, and quality initiatives. In this full-time role, you will partner with clinicians, case managers, and CDI to improve documentation, coding alignment, and outcomes.

You will lead policy development, oversee the Utilization Management Committee, and monitor performance indicators to balance patient care with cost efficiency.