Associate Medical Director, Physician Advisor for Utilization Management

Job Description

Overview:

The Associate Medical Director, Physician Advisor supports Utilization Management by providing clinical oversight, education, and guidance on medical necessity, Centers for Medicare and Medicaid Services (CMS) compliance, documentation, and resource utilization. This role partners with medical staff, hospital leadership, and payers to promote appropriate patient status, optimize length of stay, and ensure high-quality, cost-effective care. As a key member of the hospital's Utilization Review Committee (URC), the Physician Advisor conducts case reviews and helps drive compliance with regulatory standards while improving clinical and operational efficiency.

Responsibilities:

This is meant to be a general list of responsibilities, not an exhaustive list. The breadth of responsibilities is large; focus on the individual responsibilities below will vary depending upon evolving organizational priorities. The Associate Medical Director and Physician Advisor will also perform other reasonably related business/job duties as assigned. Cedars-Sinai Medical Center reserves the right to revise job duties and responsibilities as the need arises.

Utilization Management

• Review referred medical records for quality, utilization, patient status, medical necessity, and provision of services.
• Collaborate with Utilization Managers, Care Management, attending and consulting physicians regarding level of care, continued stay, length of stay, alternative levels of care, resource utilization, and complex clinical issues.
• Serve as a liaison between physicians and Utilization Management staff to ensure inpatient hospitalizations meet medical necessity criteria.
• Participate in the hospital Utilization Review Committee and support optimization of utilization management workflows with Physician Advisors and leadership.
• Perform Medicare short-stay reviews for potential Medicare Part B re-billing.
• Serve as the hospital expert on patient status determinations for all payers.
• Recommend additional medical record documentation to support medical necessity.
• Support delivery of Medicare Advanced Beneficiary Notices (ABNs), Hospital-Issued Notices of Noncoverage (HINNs), or other patient notices regarding patient financial responsibility.

Denial Management

• Prepare for and participate in payer medical director peer-to-peer discussions.
• Maintain effective working relationships with payer medical directors.

Quality

• Collaborate on quality, safety, efficiency, and readmission reduction initiatives surrounding Utilization Management
• Support organizational quality improvement efforts requiring clinician involvement.

Education

• Maintain knowledge of current state, federal, and CMS regulations, Quality Improvement Organization (QIO) requirements, and guidelines on utilization review.
• Educate providers on payer and CMS requirements, Inpatient status designations, medical necessity, documentation standards, utilization of hospital services, and alternative levels of care through meetings, presentations, newsletters, and other communications.
• Report practice pattern trends and improvement opportunities.
• Support effective communication with inpatient clinical leadership.

Administrative

• Report to the Cedars-Sinai Medical Center Medical Director of Utilization Management and collaborate with Utilization Management and Revenue Cycle leadership.
• Participate in routine meetings with Utilization Managers to review trends, education, escalation issues, and feedback.

Key Performance Indicators (KPIs)

• Support inpatient secondary reviews without final medical necessity denial.
• Complete patient status escalation reviews within four (4) hours.
• Maintain routine attendance at Utilization Review Committee meetings.
• Complete initial assessment of Medicare short-stay escalations within seven (7) business days.

Requirements:

• Licensed physician (MD/DO/MBBS).
• Holds (or is able to obtain) a medical license in good standing in the State of California.
• At least three (3) years of experience in clinical practice, preferably in an inpatient hospital setting.
• This position may be filled on a full-time or part-time basis, with a minimum commitment of 0.5 FTE
• The position includes shared coverage responsibilities, including some weekends and holidays, on a rotating basis with other Physician Advisors/physicians
• Maintains current knowledge of state, federal, and payor regulatory and contract requirements along with familiarity in quality and utilization management topics via yearly continuing medical education programs and self-study.
• American College of Physician Advisors Certified (ACPA-C) within six (6) months of hire if not already attained (preferred).
• Well versed in the use of InterQual and MCG criteria (preferred)
• Well versed in the use of Epic electronic health record (preferred)
• Exceptional organization and time management skills.
• Demonstrates the skills and competencies necessary to perform the assigned job determined through on-going skills, competency assessments, and performance evaluations.
• Ability to communicate effectively in both oral and written.
• Ability to effectively communicate with physicians and other staff.
• Ability to foster positive relations and work effectively with all disciplines within the hospital setting.

Cedars-Sinai Medical Center is one of the largest and fastest-growing nonprofit academic medical centers in the U.S., with 886 licensed beds, 2,100 physicians, 2,800 nurses, and thousands of other healthcare professionals, faculty and staff. We are in a highly desirable location in the City of Los Angeles. Competitive salary, benefits and relocation support will be provided.

Our compensation philosophy

We offer competitive total compensation that includes pay, benefits, and other incentive programs for our employees. The total pay range shown above takes into account the wide range of factors that are considered in making compensation decisions including knowledge/skills; relevant experience and training; education/certifications/licensure; and other business and organizational factors. This total pay range includes any incentive payments that may be applicable to this role. We also offer a comprehensive faculty benefits package. Pay Range: $250,000-410,000 total cash compensation.