Physician Advisor: Utilization & Quality Improvement

SUNY Downstate; New York (NY); On-site; USD 130,000 - 180,000; Full time

Job summary

SUNY Downstate Health Sciences University seeks a Physician Advisor to optimize healthcare delivery through guidance on medical necessity, utilization management, and quality improvement initiatives.

The role collaborates with physicians, case managers, CDI, and other stakeholders to ensure compliant, cost-effective care and strong documentation practices. It includes leading the Utilization Management Committee and providing education to clinicians.

Qualifications

• Experience in utilization management and regulatory compliance.
• Knowledge of ICD-10 coding and medical necessity criteria.
• Strong communication and leadership skills for physician education.

Responsibilities

• Perform Utilization Review of medical records to assess appropriateness and regulatory compliance.
• Determine medical necessity for procedures, treatments, and admissions, including inpatient vs. observation.
• Lead Discharge Planning efforts with case managers to optimize length of stay and resource use.
• Oversee Denial Management by analyzing trends and guiding appeals with clinical justification.
• Provide Education and Training to staff on utilization management principles and documentation requirements.
• Collaborate with CDI to improve physician documentation, utilization, and risk-adjusted quality measures.
• Foster intradisciplinary collaboration among physicians, nurses, and administrators to coordinate care.
• Contribute to policy development and revision of utilization management procedures.
• Lead the Utilization Management Committee to monitor KPIs related to care quality and cost.
• Engage in other duties as assigned by the CMO, with clinical duties up to 25% of the role.

Skills

Utilization Review

Medical Necessity

Discharge Planning

Denial Management

Education & Training

CDI Collaboration

Interdisciplinary Collaboration

Policy Development

Leadership & Oversight

Performance Monitoring

Job description

SUNY Downstate Health Sciences University seeks a Physician Advisor to optimize healthcare delivery through guidance on medical necessity, utilization management, and quality improvement initiatives.

The role collaborates with physicians, case managers, CDI, and other stakeholders to ensure compliant, cost-effective care and strong documentation practices. It includes leading the Utilization Management Committee and providing education to clinicians.