Job Summary and Responsibilities

Thi s is a remote position

The Utilization Management Physician Advisor II (PA) conducts clinical case reviews referred by case management staff and/or other health care professionals to meet regulatory requirements and in accordance with the system's objectives for assuring quality patient care and effective and efficient utilization of health care services.

This individual meets with case management and health care team members to discuss selected cases and make recommendations for care as well as interacting with medical staff members and medical directors of third-party payers to discuss the needs of patients and alternative levels of care. The PA performs denials management and prevention in accordance with the organization's goals and expectations. This individual reviews cases for clinical validation, performs peer-to-peer discussions and participates in appeal letter writing.

The PA further acts as a resource for the medical staff regarding federal and state utilization and quality regulations. The PA helps facilitate training for physicians. The PA must demonstrate interpersonal and communication skills and must be clear, concise and consistent in the message to all constituents.

Key Responsibilities

• Conducts medical record review in appropriate cases for medical necessity of inpatient admission, need for continued hospital stay, adequacy of discharge planning and quality care management.
• Understands the intricacies of ICD-9-CM, ICD-10-CM/PCS, MS-DRG, APR-DRG, and the Medicare Inpatient Prospective Payment System (IPPS) to make medical determinations on severity of illness, acuity, risk of mortality, and communicate with treating physicians in cooperation with the utilization team and health information personnel.
• Conducts peer-to-peer reviews with payer medical directors to discuss and advocate for the medical necessity of denied treatments, services, or hospitalizations. Presents clinical rationale, addresses concerns raised by the payer, and provides additional context to overturn denials before escalation to formal appeal.
• Reviews and analyzes denied claims to determine validity and identify opportunities for overturning inappropriate denials. Leads the appeals process by providing clinical expertise, crafting compelling appeal letters, and ensuring the submission of necessary documentation.
• Assists in communications of internal physician advisor services in the hospital newsletters and other communication vehicles to further educate the medical staff
• Provides feedback and education to the Care Management and Clinical Documentation Departments through written and verbal communication as well as appropriate tracking and trending for process improvement efforts.
• Attends and participates in facility committee meetings, such as Joint Operating Committee (JOC), as requested by Utilization Management or Care Management.

Job Requirements

• MD or DO required
• Minimum 3 years of experience as a Physician Advisor managing denials required
• Minimum 5 years of experience in Clinical Practice required
• Experience performing Peer to Peer Reviews required
• Experience submitting written and verbal appeals required
• Unrestricted license in field of practice in one or more states required.

Where You'll Work

At the heart of CommonSpirit Health's ministry are the national office departments that provide the foundational support, resources, and expertise that empower local communities to focus on what they do best-caring for patients. Our teams bring together expertise in clinical excellence, operations, finance, human resources, legal, supply chain, technology, and mission integration.

Guided by our faith-based values, the national office fosters consistency, alignment, and innovation across CommonSpirit. By centralizing expertise and leveraging economies of scale, we enable each location to operate efficiently while maintaining flexibility to address unique local community needs. From advancing digital solutions to driving health equity, these departments extend the healing presence of humankindness everywhere we serve.

Pay Range
$98.46 - $146.45 /hour