Physician Advisor

***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