Description
The Physician Advisor – Utilization Management, Denials, CDI, Coding, & Quality serves as a key clinical leader supporting Premier Health’s goals to advance documentation accuracy, revenue integrity, appropriate resource utilization, and quality performance across the health system. This role focuses on optimizing Observation rates, Initial/Final denials, case mix index (CMI), risk adjustment, clinical documentation excellence, and status/level-of-care determinations through collaboration with the CDI, Coding, Utilization Review, Care Management, Quality and Denials teams.
The Physician Advisor provides expert second-level reviews, leads provider education, conducts peer-to-peer discussions with payer medical directors, and partners closely with the CDI Manager, Coding Manager, Care/Utilization Management leadership, and Denials staff to ensure that documentation and status determinations accurately reflect the clinical complexity, severity of illness, and appropriate level of care of Premier Health’s patient population.
Key Responsibilities
1. Clinical Documentation Integrity (CDI) Leadership
- Provide secondary review of complex CDI and Coding queries escalated by the CDI and Coding teams.
- Review and resolve escalations involving Query disagreement, Clinical Validation, or incomplete response.
- Partner with the CDI Manager to establish standardized escalation criteria and ensure timely resolution of all high-impact queries.
- Conduct focused “second-look” reviews of no-CC/MCC or CC-only cases to identify missed documentation opportunities and support CMI improvement.
- Serve as a liaison between the CDI, Coding, and Physician teams to promote consistency in documentation practices.
2. Provider Engagement and Education
- Conduct one-on-one meetings with providers to review query metrics, patterns, and opportunities for improvement.
- Deliver targeted education sessions on documentation best practices, medical necessity documentation, denial prevention, MCC/CC capture, and quality measure alignment.
- Participate in residency and faculty education (Internal Medicine, Family Practice, Trauma, Critical Care, etc.) including lectures and QIPS elective rotations on CDI and professional billing documentation.
- Partner with the UR/Denials/CDI Manager and Quality leadership to develop and disseminate system-wide education tools and tip sheets.
3. CMI and Quality Improvement
- Analyze and communicate CMI trends by service line; support interventions to drive improvement aligned with Vizient benchmarks.
- Collaborate with Digital Health team to refine dashboards and enable data-driven improvement strategies.
- Participate in pre-claim mortality and risk adjustment reviews, focusing on REM score optimization and accurate capture of clinical risk variables.
- Support PSI/HAC reviews from a CDI perspective in partnership with Quality and CDI teams.
4. Interdisciplinary Collaboration
- Serve as a clinical resource to the CDI, Coding, and Quality departments on complex documentation and regulatory compliance questions.
- Partner with Digital Health to support AI-enabled CDI nudges, EHR workflow optimization, and system note-template refinement and creation for service lines.
- Contribute to system-wide initiatives related to mortality O/E, LOS O/E, and cost efficiency performance, Vizient facility ranking and Elix Hauser risk adjustment methodologies.
5. Utilization Review, Utilization Management & Denials
- Perform secondary status reviews (Inpatient vs. Observation) on cases referred by UR staff, including Condition Code 44 reviews.
- Conduct peer-to-peer reviews with payer medical directors and partner with the Denials team to craft first- and second-level appeal letters.
- Review short-stay and extended-LOS cases to identify denial/audit risk and support providers with level-of-care and throughput management.
- Participate in the Utilization Management Committee and daily huddles, supporting LOS and cost outlier analysis and PEPPER data interpretation.
Performance Expectations
- Achieve a considerable overturn rate with Inpatient stay denials
- Maintain sizeable improvements in Observation rates
- Achieve a sizeable conversion rate on escalated CDI/Coding queries.
- Demonstrate measurable CMI improvement in targeted service lines.
- Support system improvement in key Vizient metrics (Mortality O/E, Cost O/E, LOS O/E).
- Maintain provider query agreement rate ≥80% and consistent educational engagement.
- Support timely peer-to-peer completion and favorable resolution rates on inpatient denials.
Qualifications
Education: Doctor of Medicine (MD) or Doctor of Osteopathy (DO) required.
Licensure: Active Ohio medical license (or eligibility for licensure).
Experience:
– Minimum 3 years of clinical practice experience.
– Prior involvement in CDI, Utilization Management, and/or quality improvement preferred 1-2 years’ experience
– Working knowledge of utilization review criteria (InterQual/MCG), payer denial and appeal processes, and CMS status/level-of-care requirements preferred.
– Strong working knowledge of ICD-10, MS-DRG/APR-DRG systems, and risk adjustment models Vizient, CMS, Elixhauser etc.
Skills:
– Excellent communication and teaching skills.
– Ability to interpret clinical and coding guidelines with precision.
– Comfort conducting peer-to-peer discussions and supporting appeal/denial resolution.
– Proficiency with EHR systems (Epic experience preferred).
Interested Candidates Please Contact:
Eric J. Sedwick, MBA, CPC, CPRP
System Director, Physician & APP Recruitment
Premier Health
O: 937-208-2482
C: 937-901-4298
