Job Description

The Physician Advisor (PA) is a clinical leader responsible for ensuring appropriate patient care, optimizing resource utilization, and maintaining regulatory compliance. The PA conducts medical necessity and utilization reviews, manages denials and appeals, advises providers on patient status and documentation, and collaborates with Care Management and hospital leadership to improve throughput, length of stay, and overall quality outcomes.

The Physician Advisor works primarily Monday–Friday, 10:00 AM – 6:00 PM, with occasional off-hours or weekend coverage as needed to ensure continuity of the Utilization Management program.

• Review admissions, continued stays, observations, and readmissions for medical necessity and compliance.
• Apply the Two-Midnight Rule, payer guidelines, and manage denials and appeals.
• Educate providers on documentation, patient status, and utilization management processes.
• Participate in utilization management committees and escalate non-compliance trends.
• Collaborate with leadership and care teams to optimize patient flow, length of stay, and quality outcomes.
• Recommend evidence-based care coordination steps and support quality improvement initiatives.
• Maintain compliance with CMS and regulatory standards.
• Present to medical staff or administration and perform additional duties as assigned.

Minimum Qualifications:

• Graduate of an accredited medical school
• Ongoing education in quality improvement and utilization management (CME/self-study)
• Minimum 5 years recent clinical practice experience
• Active, unrestricted New Jersey physician license
• Prior Utilization Management Committee or Physician Advisor experience preferred

Preferred Qualifications & Competencies:

• Strong clinical judgment and medical necessity expertise
• Knowledge of care management, utilization review, and third-party payer requirements
• Experience with denials management and clinical documentation standards
• Familiarity with CMS, Joint Commission, and New Jersey Department of Health regulations
• Teaching, coaching, and presentation skills
• Analytical, problem-solving, and process improvement abilities
• Collaborative leadership with clinical credibility among physicians
• Persuasive communication, strong follow-through, and accountability

Note: Candidates without some specific skills must demonstrate aptitude and willingness to learn.