Physician Advisor

The Physician Advisor provides physician-to-physician reviews, clinical guidance, education, and escalation support while promoting evidence-based practices and appropriate resource utilization. Key Responsibilities Conduct physician-to-physician reviews for medical necessity, level of care, and denial prevention/appeals Support utilization review and case management teams with complex clinical decision-making Ensure appropriate admission status determinations (inpatient vs. observation) in alignment with CMS and payer guidelines Provide clinical oversight related to length of stay, care progression, and discharge planning Ensure adherence to CMS Conditions of Participation, Medicare regulations, and payer policies Support compliance with medical necessity criteria (InterQual, MCG, or equivalent) Assist with audit preparedness and response, including RAC, MAC, and commercial payer audits Partner with HIM/CDI teams to improve documentation quality and clinical accuracy Education & Physician Engagement Serve as a trusted peer resource to attending physicians and advanced practice providers Educate medical staff on regulatory requirements, utilization best practices, and documentation standards Support change management initiatives related to clinical operations and compliance Qualifications Required MD or DO with an active, unrestricted medical license Board-certified or board-eligible in a recognized specialty Clinical practice experience in an acute care or relevant healthcare setting Strong knowledge of utilization management, medical necessity, and payer regulations Excellent communication skills with the ability to conduct peer-to-peer discussions Preferred Prior experience as a Physician Advisor, Medical Director, or in Utilization Review Familiarity with CMS guidelines, InterQual, MCG, and denial management processes Experience working with case management, CDI, HIM, or revenue cycle teams Experience in a remote or consulting healthcare environment Skills & Competencies Physician-to-physician negotiation and collaboration Clinical judgment balanced with regulatory and financial awareness Data-driven decision-making Ability to influence without authority Strong written and verbal communication