PHYSICIAN ADVISOR

Riverside Healthcare•Kankakee, IL

48d•$95 - $141

About The Position

We are seeking a detail oriented Physician Advisor to join our inpatient team full time. This role serves as a key clinical and operational leader, supporting effective utilization of healthcare services and ensuring compliance with payer and regulatory requirements. The Physician Advisor provides expertise in medical necessity, documentation, care progression, and denial management, working closely with Care Management, Utilization Review, Revenue Cycle, and hospital leadership. This position reflects rotating weekend call coverage. Reporting to the Chief Medical Officer the Physician Advisor partners with medical staff leadership, providers, and resource management teams to optimize utilization practices and support organizational goals.

Requirements

MD or DO
Possess and maintain an unrestricted medical license in the State of Illinois
Minimum 5 years clinical experience in a hospital setting
Possess or develop a solid foundation in the areas of utilization management and hospital operations

Nice To Haves

Palliative Care Fellowship
American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) Health Care Quality and Management (HCQM) certification
American College of Physician Advisors certification (ACPA-C)

Responsibilities

Make recommendations on level of care including initial level of care, secondary review, and as requested by case management
Make recommendations for documentation improvement to ensure the medical record accurately reflects the patient’s clinical status, supports the level of care provided, and meets regulatory and payer requirements.
Collaborate with providers to identify opportunities for enhanced documentation that clarifies the rationale for services rendered, severity of illness, and care progression, thereby reducing the risk of denials and facilitating appropriate reimbursement.
Make recommendations on level of care, including initial level of care, secondary review, and as requested by case management.
Make recommendations for documentation improvement to ensure the medical record accurately reflects the patient’s clinical status, supports the level of care provided, and meets regulatory and payer requirements.
Review for daily level of care recommendations on cases placed in Observation
Participate in the denials management process
Be a leader in optimizing denial management
Perform peer to peer appeals and draft appeal letters for third party denials where appropriate
Apply the 2 midnight rule to Medicare reviews
Maintain compliance with Medicare rules as it applies to level of care recommendations
Stay current on changes in payer rules including CMS rules as it pertains to utilization review
Recommend and request additional and more complete medical record documentation from providers to support placement status or medical necessity
Understand and use InterQual, MCG and/or other appropriate criteria
Apply medical expertise to assist with appropriate billing for services
Provide feedback on payer denial patterns where appropriate
Aid in supporting Length of Stay (LOS) strategies (avoidable days) and quality goals.
Facilitate, mentor, and educate other physicians regarding documentation and payer requirements.
Facilitate, mentor, and educate case management on the utilization review process where appropriate
Other duties as assigned to support the unit, department, entity, and health system organization