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About the Role

The Physician Advisor provides guidance on medical necessity, utilization management, and quality improvement. They collaborate with healthcare teams to ensure compliance and promote cost-effective care.

Responsibilities

• Review medical records and documentation to assess the appropriateness of services rendered and ensure compliance with regulatory guidelines.
• Evaluate the medical necessity of procedures, treatments, and hospital admissions/level of care based on established criteria.
• Collaborate with case managers, social workers, and healthcare providers to develop care plans that meet patients' clinical needs while optimizing resource utilization.
• Lead the denial appeal process by providing clinical expertise and supporting appeals.
• Identify trends in denial cases, perform root cause analysis, and develop actionable plans to prevent future denials.
• Provide targeted physician education on documentation best practices and ensure alignment with appropriate ICD-10 coding and medical necessity criteria.
• Provide education and training to healthcare professionals on utilization management principles, documentation requirements, and regulatory compliance.
• Collaborate with CDI to ensure appropriate physician documentation with a goal to improve utilization, CMI, and risk-adjusted quality measures.
• Work closely with physicians, nurses, administrators, and other stakeholders to promote effective communication and coordination of care.
• Contribute to the development and revision of utilization management policies, protocols, and procedures.
• Lead the Utilization Management Committee.
• Monitor and evaluate key performance indicators related to utilization management, quality of care, and financial outcomes.
• Perform up to 25% clinical duties.
• Perform other duties as assigned by the CMO.

Requirements

• MD or DO degree required.
• Board certification in a relevant specialty.
• Active, unrestricted medical license in the state of New York.
• Minimum of 5 years of clinical practice experience.
• Experience in utilization management, quality improvement, or healthcare administration is preferred.
• Strong understanding of healthcare regulations, reimbursement methodologies, and clinical guidelines.
• Excellent analytical, problem-solving, and decision-making skills.
• Effective communication and interpersonal skills, with the ability to collaborate with diverse teams.
• Proficiency in electronic health record (EHR) systems and other relevant software.

Skills

• Medical Necessity Determination
• Utilization Management
• Quality Improvement
• Denial Management
• Discharge Planning
• Clinical Documentation Improvement (CDI)
• Regulatory Compliance
• Policy Development
• Performance Monitoring
• Interdisciplinary Collaboration
• Root Cause Analysis
• Physician Education

Location

• Brooklyn, NY

Work Type

• Full-time
• Part-time availability

Experience Level

• 5+ years clinical practice experience
• Experience in utilization management, quality improvement, or healthcare administration preferred

Education Level

• MD or DO degree
• Board certification in a relevant specialty
• Active, unrestricted medical license in the state of New York

About the Company

• SUNY Downstate Health Sciences University is one of the nation's leading metropolitan medical centers.
• It is the only academic medical center in Brooklyn.
• The university serves a large and diverse population.
• It is highly-ranked by Castle Connolly Medical among the top 5 leading U.S. medical schools for training doctors.

Equal Opportunity

• SUNY Downstate Health Sciences University is an affirmative action, equal opportunity employer and does not discriminate on the basis of race, color, national origin, religion, creed, age, disability, sex, gender identity or expression, sexual orientation, familial status, pregnancy, predisposing genetic characteristics, military status, domestic violence victim status, criminal conviction, and all other protected classes under federal or state laws.
• Women, minorities, veterans, individuals with disabilities and members of underrepresented groups are encouraged to apply.
• If you are an individual with a disability and need a reasonable accommodation for any part of the application process, or in order to perform the essential functions of a position, please contact Human Resources at ada@downstate.edu.