Physician Advisor

The Physician Advisor partners with medical staff, Care Management, Utilization Management, Clinical Documentation Integrity (CDI), Coding, Quality, Revenue Cycle, and hospital leadership to support medically necessary, high-quality, efficient care. The role provides physician-to-physician guidance on patient status, level of care, care progression, denials, clinical validation, and accurate documentation of severity of illness and risk of mortality. The Physician Advisor applies current regulatory, payer, coding, and utilization requirements; conducts concurrent and retrospective case reviews; educates clinicians; and helps improve quality, compliance, reimbursement, and operational performance.

PRIMARY SCOPE OF SERVICE:

The Physician Advisor supports acute-care and observation services across AtlantiCare. The role collaborates with physicians and interdisciplinary teams to ensure appropriate patient status, medical necessity, resource utilization, care progression, documentation integrity, compliant coding, denial prevention, and continuity of care. The Physician Advisor also identifies trends and improvement opportunities affecting length of stay, readmissions, quality outcomes, case mix, and revenue cycle performance.

EXPECTATIONS:

• Models AtlantiCare’s mission, values, professional standards, and commitment to patient-centered care

• Completes required orientation, education, and ongoing competency requirements

• Meets established expectations for timeliness, quality, productivity, confidentiality, compliance, and collaboration

PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:

• Conducts concurrent and retrospective medical record reviews to evaluate medical necessity, patient status, level of care, continued stay, care progression, clinical validation, and documentation completeness

• Leads denial prevention and appeal strategy by providing clinical leadership for denial prevention, payer disputes, peer-to-peer reviews, and appeals. Analyze denial trends and develop strategies to reduce avoidable denials and protect appropriate reimbursement

• Provides timely physician-to-physician consultation to attending physicians, Emergency Department clinicians, case managers, CDI specialists, coding professionals, and other members of the care team

• Physician-led CDI/clinical validation by providing physician leadership for clinical documentation integrity and clinical validation initiatives, including identifying documentation opportunities, review of complex clinical conditions, query education, and collaboration with CDI and Coding to promote accurate and compliant documentation

• DRG/CMI/MCC/CC oversight. Review DRG assignment, Severity of Illness (SOI), Risk of Mortality, MCC/CC Capture, CMI, clinical documentation trends: identify opportunities to improve documentation accuracy and ensure appropriate capture of patient complexity

• Develops and delivers targeted physician education related to medical necessity, UM, CDI, clinical validation, coding, denial prevention and regulatory changes

• Collaborates with service lines to analyze documentation, case mix, SOI, quality, and financial performance and develops targeted improvement initiatives

• Collaborates with Quality, Infection Control, CDI, Coding, and clinical leadership on clinical validation, hospital acquired conditions, mortality, readmissions, PSI, and other quality-related objectives

• Chairman of the CDI Steering Committee. Provides physician leadership and clinical expertise for the CDI Steering Committee, including development of priorities, review of documentation trends, identify educational opportunities, and coordination of CDI improvement initiates across various clinical service lines

• Data Analytics and Executive Reporting by analyzing organizational performance metrics, such as CMI, MCC/CC capture rate, observation rate, length of stay, readmissions, mortality index or O/E, denials, and present findings and recommendations to the medical staff at MEC and quarterly medical staff meetings

• Applies current regulatory and payer requirements and evidence-based criteria, including MCG or InterQual, to support compliant status and medical-necessity determinations

• Participates in peer-to-peer reviews, prepayment reviews, audits, and appeals; supports denial prevention and prepares clear clinical rationale for challenged cases

• Guides appropriate use of observation, inpatient, outpatient, and alternative levels of care, including required beneficiary notices and escalation pathways

• Partners with CDI and Coding to support documentation integrity, compliant queries, clinical validation, accurate DRG assignment, appropriate MCC/CC capture, severity of illness, risk of mortality, and case mix

• Educates and coaches physicians and other clinicians on documentation, utilization, regulatory and payer requirements, query response, denial prevention, and responsible resource use

• Participates in interdisciplinary rounds and complex-case reviews to address barriers, long stays, avoidable days, transitions of care, and readmission risk

• Analyzes trends and performance data and recommends improvements in utilization, documentation, quality, denials, length of stay, observation management, and revenue cycle outcomes

• Serves as a clinical liaison among medical staff, Care Management, Utilization Management, CDI, Coding, Quality, Revenue Cycle, payers, and hospital leadership

• Documents reviews, determinations, communications, and recommendations accurately and within established timeframes

• Maintains current knowledge of relevant laws, regulations, accreditation standards, coding guidance, payer policies, and organizational procedures

• Serves as the physician-led subject matter expert for UM, CDI, medical necessity, clinical validation, denial management, quality and revenue cycle initiatives across the organization

• Performs other duties as assigned

ADDITIONAL EXPECTATIONS AND RESPONSIBILITIES

• Participates in assigned utilization, quality, mortality, length-of-stay, readmission, CDI, Coding, and related medical staff or hospital committees

• Supports quality assessment, performance improvement, regulatory readiness, and organizational education within the scope of the role

• Presents findings, trends, and recommendations to medical staff and hospital leadership as requested

The above statement reflects the general details considered necessary to describe the principle functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position

MINIMUM JOB SPECIFICATIONS:

• MD or DO from an accredited medical school; current, unrestricted New Jersey medical license and eligibility for AtlantiCare medical staff membership

• Board certification in a clinical specialty; certification in health care quality, utilization management, or physician advising preferred

• Minimum five years of recent clinical practice experience; acute-care experience preferred

• Working knowledge of utilization management, CDI, coding and reimbursement, medical necessity, level-of-care criteria, denials and appeals, and applicable federal, state, and payer requirements

• Experience with evidence-based criteria such as MCG and proficiency with electronic health records and related clinical systems

• Strong clinical judgment, analytical ability, communication, physician engagement, education, collaboration, organization, and change-management skills