Physician Advisor

The Physician Advisor serves as a physician leader partnering with Care Management, Utilization Management (UM), Clinical Documentation Improvement (CDI), Health Information Management (HIM), Revenue Cycle, Quality, and clinical service lines to ensure medically appropriate, timely, and accurately documented care. This role provides expert clinical review, peer-to-peer consultation, and physician-to-physician communication to support correct patient status determination, level of care, and regulatory compliance. The Physician Advisor strengthens clinical documentation and severity capture, supports denial prevention and appeals, and advances quality and throughput initiatives while promoting a culture of collaboration and evidence-based practice.

Education

• MD or DO - Required

Work Experience:

• Current clinical experience in acute care (or relevant recent experience) - Required
• Five years post residency as attending physician - Required
• Strong understanding of medical necessity, payer rules, and documentation standards (or demonstrated ability to learn quickly) - Required
• Excellent communication skills for physician-to-physician discussions and interdisciplinary collaboration - Required
• Prior experience as a Physician Advisor, Medical Director, Hospitalist leader, UM physician, CDI physician champion, or similar role - Preferred
• Familiarity with InterQual criteria and denial/appeal workflow - Preferred
• Experience with CDI, clinical validation, risk adjustment, and documentation education - Preferred
• Knowledge of CMS regulations, Conditions of Participation, and value-based program - Preferred

Licenses and Certifications

• Active (or eligible) Missouri medical license - Required
• Board certified or board eligible in a relevant specialty (e.g., Internal Medicine, Family Medicine, Hospital Medicine) - Required

• Primarily office/administrative work with on-site clinical presence as needed; may require participation in rounds or meetings in patient care areas.
• May include occasional evening/weekend availability to support time-sensitive payer peer-to-peers or urgent reviews.

Essential Functions

A. Utilization Management / Level of Care Determination

• Provides physician oversight and guidance for medical necessity, admission status (inpatient vs. observation), continued stay, and level-of-care determinations in collaboration with UM and Care Management teams.
• Conducts concurrent reviews of selected cases with high risk for denial, complex status determination, or payer scrutiny; identifies opportunities for early intervention.
• Serves as the physician resource for peer-to-peer discussions with payers; communicates clinical rationale and ensures documentation supports medical necessity.
• Supports timely progression of care by addressing barriers to discharge, reducing avoidable days, and collaborating on escalation pathways.
• Advises on appropriate use of InterQual and supports consistent application across service lines.

B. Denials Prevention, Management, and Appeals

• Partners with Revenue Cycle/Denials teams to reduce preventable denials through concurrent interventions and physician education.
• Reviews adverse determinations and supports development of appeal strategies, including medical necessity narratives, supporting literature, and case summaries.
• Participates in denial trend analysis; identifies root causes and implements targeted action plans with clinical and operational leaders.
• Provides feedback loops to service lines regarding documentation, order clarity, and decision-making patterns that contribute to denials.

CDI – Clinical Documentation Improvement Responsibilities

The Physician Advisor plays a critical leadership role in optimizing the accuracy, specificity, and completeness of the medical record to reflect patient acuity, risk, and clinical complexity.

• Serves as a physician champion for CDI, ensuring documentation accurately captures principal diagnosis, comorbidities/complications (CC/MCC), severity of illness (SOI), risk of mortality (ROM), and appropriate DRG assignment when applicable.
• Partners with CDI specialists to address documentation gaps in real time, including conditions such as sepsis, malnutrition, respiratory failure, encephalopathy, AKI/CKD staging, heart failure specificity, and other high-impact diagnoses.
• Provides physician-to-physician support for CDI queries to drive clarity, clinical validation, and consistent documentation practices.
• Collaborates with HIM and Coding to support clinical validation and DRG downgrades prevention by ensuring documentation aligns with clinical indicators and treatment.
• Leads and/or supports provider education on best practices for documentation, including:
  • Accurate problem list management and diagnosis specificity
  • Linking diagnoses to clinical indicators
  • Documentation of treatment rationale and response
  • Clear attribution of present-on-admission (POA) and hospital-acquired conditions (HAC) considerations
• Partners with Quality and Patient Safety teams to align documentation improvement with core measures, risk adjustment, publicly reported outcomes, and value-based performance.
• Uses CDI dashboards/analytics to identify trends, outliers, and opportunities for improvement; supports service-line-level action plans.

Quality, Compliance, and Clinical Effectiveness

• Supports regulatory and accreditation compliance related to documentation, medical necessity, and utilization review (e.g., CMS Conditions of Participation, payer rules).
• Partners with Quality/Clinical Effectiveness to promote appropriate care pathways, reduce variation, and improve outcomes.
• Identifies improvement opportunities impacting patient flow, LOS, readmissions, and avoidable complications.
• Contributes to development and refinement of policies/procedures for admission status, escalation, and clinical documentation standards.

Collaboration & Communication

• Builds strong partnerships with hospitalists, specialists, nursing, CDI, UM, case management, coding, and revenue cycle teams.
• Provides timely consultation and clear recommendations while maintaining collegial relationships and focusing on patient-centered care.
• Participates in interdisciplinary rounds/escalation huddles as needed to address complex cases, discharge barriers, and documentation needs.
• Represents Mosaic Life Care in committees/workgroups related to utilization, denials, CDI, documentation integrity, and throughput.

Education & Provider Engagement

• Develops and delivers provider education on medical necessity, documentation integrity, and payer requirements.
• Creates quick-reference guidance, tip sheets, and escalation pathways that support consistent practice.
• Encourages a continuous improvement culture through coaching, data transparency, and feedback.

Data & Reporting

• Reviews and interprets performance metrics including denial rates, observation utilization, LOS, readmissions, CDI query response rates, SOI/ROM, CC/MCC capture, and documentation-related quality indicators.
• Uses data to prioritize interventions and evaluate the effectiveness of initiatives.