Care Management & Utilization Management Physician Advisor

City/State: White Plains, New York Department: Office of the CMO Work Shift: Day Work Days: DAYS VARY Scheduled Hours: Hours Vary Hours Per Pay Period: 75 Pay Rate/Range: $250,000 to $500,000

Job Summary The Care Management & Utilization Management Physician Advisor is a physician leader who works across clinical and operational domains to improve the quality, efficiency, coordination, financial integrity, and value of care. The Physician Advisor serves as a trusted liaison among the medical staff, Patient Care Services, Care Management, Utilization Management, Clinical Documentation Integrity (CDI), Coding, Quality and Patient Safety, Transitional Care, Access, Patient Relations, Patient Experience, Finance, Revenue Cycle, and hospital administration. The role extends beyond traditional utilization review and supports hospital-wide clinical operations, accurate clinical documentation and coding, risk adjustment, care progression, physician engagement, performance improvement, high-value care, and complex-case problem solving. The Physician Advisor helps operationalize the organization's Avoid-Adjust-Improve quality strategy. AVOID focuses on preventing inaccurate representation of the patient's clinical condition, including inappropriate principal diagnosis selection, clinical validation concerns, and incorrect cohort assignment. ADJUST focuses on ensuring that clinically supported patient complexity and severity are accurately documented and coded. IMPROVE focuses on measurable improvement in clinical outcomes, safety, reliability, care delivery, and patient experience. The Physician Advisor is expected to integrate all three domains so that organizational performance reflects both the care delivered and the true complexity of the patients served.

The Physician Advisor applies clinical judgment, regulatory knowledge, data, and physician leadership to promote documentation and coding that are clinically valid, compliant, and consistent with the patient's actual condition while simultaneously improving care delivery and outcomes.

1. Physician Leadership and Clinical Operations • Serve as a visible physician leader and clinical-operational partner across hospital departments, translating organizational priorities into physician action and sustainable clinical practice. • Act as a physician liaison among medical staff, nursing, Care Management, Utilization Management, CDI, Coding, Quality and Patient Safety, Patient Relations, Patient Experience, Transitional Care, Access, Finance, Revenue Cycle, and administration. • Serve as a physician escalation resource for complex clinical, documentation, utilization, payer, and operational issues requiring cross-disciplinary problem solving, alignment, or de-escalation. • Identify recurring barriers to high-quality, efficient, accurately represented care and partner with operational leaders to redesign workflows, clarify accountability, and improve execution. • Support organizational initiatives that promote the right care, at the right time, in the right setting, with appropriate consideration of clinical need, patient goals, expected outcomes, payer requirements, and resource stewardship. 2. Avoid-Adjust-Improve and Enterprise Performance Improvement • Support the organization's Avoid-Adjust-Improve strategy as an integrated approach to accurate representation of care, recognition of patient complexity, and measurable improvement in clinical outcomes. • Under AVOID, identify and help prevent inaccurate principal diagnosis selection, clinically unsupported diagnoses, incorrect present-on-admission attribution, or other documentation/coding issues that may place patients in an inappropriate clinical or external-reporting cohort. • Under ADJUST, work with physicians, CDI, Coding, Quality, and analytics teams to ensure that clinically supported comorbidities, complications, severity, and other risk variables are accurately represented in the medical record and coded data. • Under IMPROVE, use clinical judgment and performance data to identify opportunities to reduce preventable harm, mortality, complications, avoidable delays, preventable readmissions, unnecessary utilization, and unwarranted variation. • Lead or participate in multidisciplinary performance improvement initiatives focused on quality, safety, reliability, patient flow, care coordination, clinical documentation, risk-adjusted outcomes, and value. • Help translate performance signals into actionable interventions for physicians and clinical teams and evaluate whether those interventions produce sustained improvement. 3. Clinical Documentation Integrity, Coding, and Risk Adjustment • Serve as the physician partner to CDI and Coding teams, providing clinical interpretation, physician-to-physician engagement, and escalation support for complex documentation and coding issues. • Promote accurate, complete, timely, and clinically supported documentation of diagnoses, procedures, severity of illness, complications, comorbidities, and other elements that affect coding, reimbursement, external reporting, and risk-adjusted outcomes. • Review selected cases in which documentation, coding, principal diagnosis selection, clinical validation, or risk adjustment may not accurately reflect the patient's condition or course of care. • Partner with Coding and CDI to improve the accuracy of principal diagnosis selection, present-on-admission status, clinical validation, and clinically appropriate capture of patient complexity while maintaining compliance with applicable coding and regulatory standards. • Provide physician education and individualized feedback regarding documentation practices, terminology, query response, clinical validation, and the downstream impact of documentation on coded data, risk-adjusted outcomes, payer review, and external performance measurement. • Collaborate with Quality, analytics, Finance, Revenue Cycle, and clinical leaders to understand how documentation and coded data affect observed-to-expected performance, mortality, complications, readmissions, resource use, reimbursement, and external benchmarking. • Identify trends in documentation-related or coding-related denials and partner with CDI, Coding, Utilization Management, Revenue Cycle, and medical staff leaders to address recurring causes. • Support targeted audits and performance reviews when there is concern that documented or coded data do not accurately reflect clinical reality. • Maintain a compliance-centered approach: documentation and coding recommendations must be clinically valid, evidence-based, and supported by the medical record. 4. Care Management and Utilization Management • Partner closely with Patient Care Services leadership, the Director of Care Management, and Care Management teams to strengthen care coordination, care progression, and complex-case management. • Provide physician leadership for admission, continued-stay, level-of-care, and medical-necessity questions in collaboration with Care Management and Utilization Management teams. • Support timely and appropriate inpatient and observation status decisions in accordance with regulatory and payer requirements. • Participate in peer-to-peer reviews with payers and provide clinical leadership in medical-necessity denials, appeals, and related escalation processes. • Participate in Care Management conferences and multidisciplinary case reviews to resolve barriers to discharge, prolonged hospitalization, and other avoidable delays. • Participate in the Utilization Review Committee and support compliance with applicable Centers for Medicare & Medicaid Services (CMS) Conditions of Participation and payer requirements. 5. Care Progression, Access, and Transitions Across the Continuum • Partner with clinical teams, Care Management, and the Access team to support appropriate patient placement, transfers, level of care, and efficient progression through the hospital. • Provide physician input when clinical or operational barriers affect access, placement, transfer, discharge, or transition to the next appropriate site of care. • Partner with the Transitional Care Team to identify patients and clinical situations in which physician involvement may improve continuity, follow-up, adherence to the care plan, or reduction of preventable readmissions. • Support multidisciplinary planning for high-risk and complex patients and help resolve clinical barriers that interfere with safe and effective transitions. • Collaborate across inpatient, ambulatory, home care, post-acute, and community settings as appropriate to strengthen continuity across the care continuum. 6. High-Value Care and Reduction of Unwarranted Variation • Promote evidence-based, patient-centered, and resource-conscious clinical practice across the medical staff. • Identify opportunities to reduce unwarranted variation in care, unnecessary testing or treatment, avoidable use of high-cost resources, and care delivered in a suboptimal setting. • Support development, adoption, and evaluation of clinical pathways, care standards, and other approaches that improve reliability and value. • Work with physician and operational leaders to address outlier utilization or practice patterns through data, education, peer engagement, and performance improvement rather than solely through administrative review. 7. Patient Relations and Patient Experience • Collaborate with Patient Relations and Patient Experience teams when physician leadership, clinical interpretation, or escalation is needed to address patient and family concerns. • Assist in resolving complex concerns involving physician communication, clinical expectations, care coordination, or transitions of care. • Use themes from patient feedback, complaints, and grievances to identify recurring clinical or operational opportunities and support improvement initiatives. • Partner with clinical leaders to improve physician communication and patient-centered care while recognizing that overall Patient Experience strategy remains the responsibility of the Patient Experience department. 8. Quality, Safety, and Regulatory Partnership • Collaborate with Quality and Patient Safety teams in the identification and resolution of selected quality-of-care, safety, reliability, and care-delivery issues. • Maintain current knowledge of Medicare, Medicaid, commercial payer, regulatory, documentation, coding, clinical validation, medical-necessity, and patient-status requirements relevant to physician advisory work. • Serve as a physician resource to hospital leadership and clinical teams regarding applicable regulatory and payer requirements. • Support development and revision of policies and processes related to CDI, coding, risk adjustment, Care Management, Utilization Management, care progression, and other areas within the Physician Advisor's scope. • Participate in regulatory, payer, audit, or performance reviews as appropriate to the role. 9. Data, Analytics, and Performance Management • Use clinical, operational, utilization, documentation, coding, risk-adjustment, quality, patient experience, and financial data to identify performance opportunities and prioritize Physician Advisor interventions. • Collaborate with analytics and operational teams to develop actionable dashboards and reports that support clinical decision-making and performance improvement. • Evaluate observed and expected outcomes, cohort assignment, case mix, documentation trends, denial patterns, utilization, and other performance signals to identify whether opportunity lies in accurate representation, risk adjustment, or actual care delivery. • Provide physician-specific or service-line feedback when appropriate to improve engagement, reduce unwarranted variation, strengthen documentation, and support organizational goals. • Monitor the impact of interventions and adjust strategies when expected improvement is not achieved. 10. Education, Change Management, and Physician E