Physician Advisor

Utilization Management

• Participate in twice-daily observation huddles to support appropriate patient status determinations and address barriers to conversion or discharge.
• Review observation cases for medical necessity and apply CMS Two-Midnight Rule criteria when appropriate.
• Conduct admission reviews, continued stay reviews, second-level reviews, Medicare short-stay reviews, pre-bill/post-bill reviews, and readmission reviews.
• Provide physician and staff education regarding utilization management, medical necessity requirements, and patient status determination.
• Collaborate with Emergency Department physicians, Utilization Review, and Case Management teams regarding status determination and alternative levels of care.
• Consult with providers regarding documentation deficiencies affecting medical necessity determinations.
• Perform medical necessity appeals and peer-to-peer reviews with commercial and governmental payers.
• Lead and support denial prevention, denial management, and appeals initiatives.
• Serve as a liaison between providers and payers to facilitate approvals and reduce denials.
• Support and participate in Utilization Management Committee activities.
• Ensure compliance with CMS regulations, payer requirements, and utilization management best practices.

Throughput & Length of Stay Management

• Participate in bi-weekly Long Length of Stay (LOS) meetings to identify barriers to care and facilitate discharge planning.
• Participate in daily escalation huddles to address patient flow challenges.
• Collaborate with hospital leadership, physicians, nursing, and care management teams to improve patient throughput and reduce avoidable delays.
• Provide feedback to physicians regarding level-of-care determinations, length of stay performance, and quality outcomes.
• Assist providers in improving clinical documentation to support appropriate reimbursement and regulatory compliance.
• Recommend evidence-based care strategies and next steps in coordination of care.
• Promote interdisciplinary communication, collaboration, and care coordination.
• Support organizational quality improvement initiatives requiring physician leadership and participation.

Leadership & Physician Engagement

• Serve as a resource to physicians regarding federal and state utilization, quality, and regulatory requirements.
• Educate providers regarding documentation requirements, medical necessity criteria, and payer expectations.
• Participate in hospital committees focused on evidence-based medicine, quality improvement, and patient outcomes.
• Develop and support clinical protocols that promote optimal standards of care.
• Present utilization management, quality, and performance improvement initiatives to Medical Staff, Administration, and the Board as needed.
• Perform additional duties and special projects in support of organizational goals.

The Physician Advisor (PA) role is responsible for completing detailed reviews of complex patient cases to ensure appropriate plan of care and resource management. An enhanced case review by the PA is necessary to reduce denials and resource utilization issues. PA responsibilities include but are not limited to enhanced utilization review, comprehensive management of denials and appeals, effective partnership with Care Management and Social Work, expertise in insurance regulation and compliance, and availability for provider education.

The Physician Advisor works primarily Tuesday & Thursday 1:30pm-6:30pm

Occasional calls off-hours if major, time-sensitive issues should arise

May work other hours to assure UM program elements are in place and functioning off-hours

St. Joseph's Health is recognized for the expertise and compassion of its highly skilled and responsive staff. The combined efforts of the organization's outstanding physicians, superb nurses, and dedicated clinical and professional staff have made us one of the most highly respected healthcare organizations in the state, the largest employer in Passaic County, and one of the nation's "100 Best Places to Work in Health Care".

St. Joseph's University Medical Center is an academic tertiary care medical center and state designated trauma center, located on the Paterson campus, regularly accepts referrals of difficult or unusual cases from other hospitals and physicians and performs both complex and routine procedures.

The Medical Center offers a full complement of specialty and subspecialty services including ambulatory, behavioral health, cardiovascular, emergency/trauma, internal medicine, neuroscience, oncology, orthopedic/spine, rehabilitation, surgical specialty, women's health, imaging and pediatrics.

The nursing team at St. Joseph's University Medical Center, which includes St. Joseph's Children's Hospital, has held the Magnet Award for Nursing Excellence, the profession's highest honor, since 1999. They are also recipients of the prestigious 2010 Magnet Prize - one of only 8 Magnet-designated hospitals to ever receive The Magnet Prize, and the only one worldwide to receive the 2010 award.