Physician Advisor

St. Joseph's Health•Paterson, NJ

5d•Onsite

About The Position

The Physician Advisor (PA) role is responsible for completing detailed reviews of complex patient cases to ensure appropriate plan of care and resource management. An enhanced case review by the PA is necessary to reduce denials and resource utilization issues. PA responsibilities include but are not limited to enhanced utilization review, comprehensive management of denials and appeals, effective partnership with Care Management and Social Work, expertise in insurance regulation and compliance, and availability for provider education. The Physician Advisor works primarily Tuesday & Friday 9am-2pm. Occasional calls off-hours if major, time-sensitive issues should arise. May work other hours to assure UM program elements are in place and functioning off-hours.

Requirements

Graduate of an accredited medical school.
Minimum of five (5) years of recent clinical practice experience.
Current and unrestricted New Jersey physician license required.

Nice To Haves

Additional education in Quality Management and Utilization Management through continuing medical education programs and self-study preferred.
Strong clinical acumen and medical judgment.
Knowledge of care management principles, utilization review processes, and acute care medical necessity criteria.
Working knowledge of commercial payer requirements and medical necessity guidelines.
Experience with concurrent and retrospective denials management and appeals.
Understanding of clinical, quality, and administrative aspects of healthcare delivery.
Familiarity with clinical documentation improvement initiatives.
Working knowledge of Centers for Medicare & Medicaid Services (CMS), The Joint Commission, and New Jersey Department of Health regulations.
Excellent written, verbal, presentation, and interpersonal communication skills.
Strong teaching, coaching, and physician engagement abilities.
Exceptional analytical, critical-thinking, and problem-solving skills.
Knowledge of process improvement methodologies.
Ability to build collaborative relationships across multidisciplinary teams.
Clinical credibility and the ability to influence physicians and healthcare leaders.
Persuasive, energetic, and solution-oriented leadership style.
Strong organizational skills with demonstrated ability to drive initiatives to completion.
Candidates who may not possess every preferred qualification but demonstrate the aptitude and commitment to develop these competencies are encouraged to apply.
Candidates without some specific skills must demonstrate aptitude and willingness to learn.

Responsibilities

Participate in twice-daily observation huddles to support patient status determinations and address barriers to conversion or discharge.
Review observation cases for medical necessity and apply CMS Two-Midnight Rule criteria when appropriate.
Perform admission reviews, continued stay reviews, second-level reviews, Medicare short-stay reviews, pre-bill/post-bill reviews, and readmission reviews.
Provide physician and staff education regarding utilization management, medical necessity requirements, and patient status determination.
Provide guidance to Emergency Department providers and Utilization Review/Case Management teams regarding appropriate status determinations and alternatives to acute care.
Consult with providers regarding documentation deficiencies affecting medical necessity determinations.
Perform medical necessity appeals and peer-to-peer reviews across all payer groups.
Lead and support denial prevention, denial management, and appeals initiatives.
Serve as a liaison between providers and payers to facilitate approvals and minimize denials.
Support and participate in Utilization Management Committee activities.
Ensure compliance with CMS regulations, payer requirements, and utilization management best practices.
Participate in bi-weekly Long Length of Stay (LOS) meetings to identify barriers to care and facilitate discharge planning.
Participate in daily escalation huddles to address patient flow and operational challenges.
Collaborate with hospital leadership, physicians, nursing, and care management teams to improve throughput and reduce avoidable delays.
Provide feedback to physicians regarding level-of-care determinations, length of stay performance, and quality outcomes.
Assist providers in improving clinical documentation to support reimbursement and regulatory compliance.
Recommend evidence-based care strategies and next steps in patient care coordination.
Promote communication, collaboration, and interdisciplinary teamwork across the healthcare continuum.
Support quality improvement initiatives requiring physician leadership and participation.
Collaborate with Utilization Management teams to provide physician education and support process improvement efforts.
Participate in hospital committees focused on evidence-based medicine, quality improvement, and patient outcomes.
Assist in the development of clinical protocols that support optimal standards of care.
Present utilization management and quality initiatives to Medical Staff, Administration, and Board members as appropriate.
Serve as a physician resource regarding utilization management, medical necessity, and regulatory compliance.
Perform additional duties and special projects as assigned.