Physician Advisor

About this role

***WE ARE CURRENTLY FULLY STAFFED, BUT OUR NEEDS CAN CHANGE AT ANY TIME,
AND WE ARE STILL ACCEPTING APPLICATIONS***
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

Originally posted on Himalayas