The Physician Advisor works collaboratively with case managers, social workers, and admitting physicians to ensure patients are placed at the correct level of care and that medical necessity is well-documented. The PA also addresses issues around clinical documentation, billing compliance (including CMS 2-Midnight Rule), length of stay, readmissions, and quality metrics. This position reports through a matrix structure to the Corporate Physician Advisor, Chief Quality and Integration Officer (CQIO), and entity-level CMO/CEO.

Key Responsibilities:

• Provide real-time clinical guidance to ensure appropriate level of care and utilization
  

• Support accurate clinical documentation to reflect severity of illness and medical necessity
  

• Collaborate with providers and hospital staff to improve care transitions and reduce LOS/readmissions
  

• Conduct post-discharge audits and respond to payer reviews or appeals
  

• Educate medical staff on CMS regulations, InterQual/MCG criteria, and billing requirements
  

• Drive clinical practice improvements that enhance patient care and hospital performance
  

• Promote interdepartmental collaboration and communication through education and support
  

• Maintain knowledge of current compliance standards and payer guidelines through ongoing education
  

Qualifications:

• MD or DO degree from an accredited institution
  

• Active medical license in Insert State
  

• Minimum 3 years of clinical practice experience
  

• Experience with medical necessity reviews and use of MCG or InterQual criteria
  

• Knowledge of CMS Conditions of Participation, billing regulations, and the 2-Midnight Rule
  

• Strong communication, organization, and critical thinking skills
  

Certifications:

• Board Certification by ABQAURP (or equivalent) required within 1 year of hire
  

• Physician Advisor Certification preferred at time of hire
  

Additional Skills:

• Ability to manage multiple deadlines and shifting priorities
  

• Proficiency in relevant technology and EMR systems
  

• Ability to lead and educate in both individual and group settings
  

• Demonstrated professionalism and sound clinical judgment