Associate Medical Director, Physician Advisor for Utilization Management

Cedars-Sinai•Beverly Hills, CA

11h•$250,000 - $410,000•Onsite

About The Position

The Associate Medical Director, Physician Advisor supports Utilization Management by providing clinical oversight, education, and guidance on medical necessity, Centers for Medicare and Medicaid Services (CMS) compliance, documentation, and resource utilization. This role partners with medical staff, hospital leadership, and payers to promote appropriate patient status, optimize length of stay, and ensure high-quality, cost-effective care. As a key member of the hospital's Utilization Review Committee (URC), the Physician Advisor conducts case reviews and helps drive compliance with regulatory standards while improving clinical and operational efficiency.

Requirements

Licensed physician (MD/DO/MBBS).
Holds (or is able to obtain) a medical license in good standing in the State of California.
At least three (3) years of experience in clinical practice, preferably in an inpatient hospital setting.
Maintains current knowledge of state, federal, and payor regulatory and contract requirements along with familiarity in quality and utilization management topics via yearly continuing medical education programs and self-study.
Exceptional organization and time management skills.
Demonstrates the skills and competencies necessary to perform the assigned job determined through on-going skills, competency assessments, and performance evaluations.
Ability to communicate effectively in both oral and written.
Ability to effectively communicate with physicians and other staff.
Ability to foster positive relations and work effectively with all disciplines within the hospital setting.

Nice To Haves

American College of Physician Advisors Certified (ACPA-C) within six (6) months of hire if not already attained (preferred).
Well versed in the use of InterQual and MCG criteria (preferred)
Well versed in the use of Epic electronic health record (preferred)

Responsibilities

Review referred medical records for quality, utilization, patient status, medical necessity, and provision of services.
Collaborate with Utilization Managers, Care Management, attending and consulting physicians regarding level of care, continued stay, length of stay, alternative levels of care, resource utilization, and complex clinical issues.
Serve as a liaison between physicians and Utilization Management staff to ensure inpatient hospitalizations meet medical necessity criteria.
Participate in the hospital Utilization Review Committee and support optimization of utilization management workflows with Physician Advisors and leadership.
Perform Medicare short-stay reviews for potential Medicare Part B re-billing.
Serve as the hospital expert on patient status determinations for all payers.
Recommend additional medical record documentation to support medical necessity.
Support delivery of Medicare Advanced Beneficiary Notices (ABNs), Hospital-Issued Notices of Noncoverage (HINNs), or other patient notices regarding patient financial responsibility.
Prepare for and participate in payer medical director peer-to-peer discussions.
Maintain effective working relationships with payer medical directors.
Collaborate on quality, safety, efficiency, and readmission reduction initiatives surrounding Utilization Management.
Support organizational quality improvement efforts requiring clinician involvement.
Maintain knowledge of current state, federal, and CMS regulations, Quality Improvement Organization (QIO) requirements, and guidelines on utilization review.
Educate providers on payer and CMS requirements, Inpatient status designations, medical necessity, documentation standards, utilization of hospital services, and alternative levels of care through meetings, presentations, newsletters, and other communications.
Report practice pattern trends and improvement opportunities.
Support effective communication with inpatient clinical leadership.
Report to the Cedars-Sinai Medical Center Medical Director of Utilization Management and collaborate with Utilization Management and Revenue Cycle leadership.
Participate in routine meetings with Utilization Managers to review trends, education, escalation issues, and feedback.