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.

Responsibilities
* Provide physician oversight for medical necessity, admission status,
continued stay, and level-of-care decisions in partnership with Utilization
Management and Care Management.
* Perform concurrent review of high-risk or complex cases, support payer
peer-to-peer discussions, and ensure documentation supports medical
necessity.
* Advance timely progression of care by addressing discharge barriers, reducing
avoidable days, and promoting consistent InterQual use across service lines.
* Partner with Revenue Cycle and denials teams to prevent avoidable denials
through early intervention, physician education, and feedback on
documentation and order patterns.
* Review adverse determinations, support appeals with strong clinical
narratives and evidence, and use denial trends to drive corrective action
plans.
* Serve as the physician champion for CDI by improving documentation accuracy,
specificity, severity capture, and appropriate DRG assignment.
* Work with CDI, HIM, and Coding to close documentation gaps in real time,
support clinical validation, and prevent DRG downgrades.
* Educate providers on best-practice documentation, including diagnosis
specificity, linkage to clinical indicators, treatment rationale, and POA/HAC
considerations.
* Align documentation improvement with quality, patient safety, risk
adjustment, public reporting, and value-based performance goals.
* Support regulatory and accreditation compliance, promote evidence-based care
pathways, reduce variation, and identify opportunities to improve LOS,
readmissions, complications, and patient flow.
* Build strong interdisciplinary partnerships, provide timely and collegial
consultation, participate in rounds and escalation huddles, and represent the
organization in key committees and workgroups.
* Use dashboards and performance metrics such as denials, observation
utilization, LOS, readmissions, CDI response rates, SOI/ROM, and CC/MCC
capture to prioritize interventions and evaluate results.

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

Qualifications

Working Conditions/Physical Requirements

* 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.