Physician Advisor- Utilization Management & Clinical Documentation Integrity- ONSITE

Key Responsibilities And Essential Functions

• Partner with CDI specialists to improve clinical documentation accuracy and completeness.
• Provide physician-to-physician education on documentation requirements related to: Severity of illness, Risk of mortality, CC/MCC capture, DRG assignment.
• Assist with case mix index (CMI) improvement initiatives.
• Review complex cases for documentation opportunities that accurately reflect patient acuity.
• Provide physician guidance for medical necessity determinations.
• Review cases for appropriate inpatient vs observation status.
• Support case management staff with complex utilization reviews.
• Conduct peer-to-peer reviews with payers.
• Collaborate with care management teams to identify and address barriers to timely discharge.
• Work with clinical teams to reduce avoidable length of stay and excess days.
• Participate in daily multidisciplinary rounds and discussions to address throughput challenges and delayed discharges.
• Teach Internal Medicine Residents about the role of a Physician Advisor.
• Review cases with extended length of stay to identify clinical, operational, or documentation barriers contributing to opportunity days.
• Work with case management, nursing leadership, and service line leaders to address drivers of avoidable hospital days.
• Support hospital initiatives aimed at improving patient flow and capacity management.
• Resolve delays related to: Clinical decision-making, Documentation gaps, Discharge readiness, Specialist consultation delays.
• Write and support clinical appeal letters.
• Participate in denials management strategy.
• Identify systemic issues contributing to denials and implement improvement strategies.
• Provide education to medical staff on documentation, utilization management, and efficient care delivery.
• Present findings at: Medical staff meetings, Service line meetings, Quality committees.
• Serve as a physician champion for documentation improvement, medical necessity compliance, and hospital throughput.
• Ensure hospital practices align with: CMS Conditions of Participation, Medicare documentation rules, Two-midnight rule, Utilization review regulations.
• Partner with Quality and Compliance departments to ensure regulatory alignment.
• Monitor, analyze, and actively strive to improve key hospital performance metrics including, but not limited to: Case Mix Index (CMI), Length of Stay Index (Observed vs Expected LOS and %GMLOS), Opportunity Days, Observation rates, Medical necessity denial rates, CC/MCC capture rate.
• Identify opportunities for clinical, operational, and documentation improvement.

Qualifications

• MD or DO degree from an accredited institution.
• Board Certified in a recognized medical specialty.
• Active unrestricted medical license to practice medicine in the state of Georgia.
• Minimum of 5 years clinical practice experience.
• Experience working in hospital-based care.
• Demonstrated leadership, people management, and team building skills.
• Excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.
• Ability to develop and implement strategic clinical plans.
• Excellent oral and written communication skills.
• Ability to interact effectively with key internal and external constituents using collaboration and customer service skills that promote excellence in the patient experience.
• Customer service orientation.
• Demonstrated confidence, initiative, and integrity in work practices.
• Goal-directed and well organized.
• High level of dependability and accuracy.
• Adept at conflict management.
• Ability to work independently.
• Strong negotiation and persuasion skills.
• Strong computer skills and working knowledge of EMR’s.
• Broad knowledge base of health care delivery and case management within a managed care environment.
• Comprehensive knowledge of Utilization Review, levels of care, and observation status.