Physician Advisor Specialist

Job Summary

The Physician Advisor Specialist is responsible for coordinating Physician Advisor (PA) peer-to-peer (P2P) reviews, managing case assignments, tracking outcomes, and facilitating communication with external payers, auditors, and internal teams. This role collaborates with Utilization Review (UR), Shared Service Center (SSC), and Revenue Cycle teams to support denial management strategies and payer interactions. The Physician Advisor Specialist ensures timely case scheduling, documentation accuracy, and compliance with corporate, payer, and regulatory requirements.

Essential Functions

• Manages the coordination of Physician Advisor (PA) peer-to-peer (P2P) reviews, including assigning, scheduling, and tracking cases that require review.
• Schedules and manages multiple Physician Advisor calendars, ensuring timely review completion and follow-ups for observation (OBS) vs inpatient (IP) cases.
• Communicates with insurance payers to schedule and confirm the status of peer-to-peer reviews, maintaining awareness of payer scheduling practices and deadlines.
• Works closely with Physician Advisors, Utilization Review, and Denial Management teams, ensuring timely resolution of denials and P2P case reviews.
• Maintains and updates case information in multiple case management software applications, ensuring documentation accuracy and compliance with corporate and payer guidelines.
• Tracks and analyzes payer trends, behaviors, and common issues, collaborating with managed care and contracting teams to improve payer negotiations and denials management strategies.
• Supports SSC, Revenue Management, and Utilization Review teams, providing insights on payer behaviors, downgrade protocols, and review determinations.
• Maintains knowledge of commercial payer denial policies, CMS requirements, corporate UR protocols, and contractual agreements, ensuring compliance with regulatory and corporate standards.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualifications

• H.S. Diploma or GED required
• Bachelor's Degree preferred
• 2-4 years of experience in healthcare administration, utilization review, payer relations, or revenue cycle operations required
• Experience working with physician advisors, case management, managed care, or insurance payers preferred

Knowledge, Skills and Abilities

• Strong understanding of peer-to-peer review coordination, utilization review processes, and denial management strategies.
• Proficiency in Microsoft Office Suite (Excel, Outlook, Word, Teams), Google Suite, and payer portals.
• Ability to manage multiple priorities, physician schedules, and payer interactions efficiently.
• Excellent written and verbal communication skills, with the ability to engage with physicians, payers, and internal teams professionally.
• Strong analytical skills, with the ability to track and report payer trends and review determinations.
• Highly organized and detail-oriented, with the ability to independently manage workflows and meet deadlines.
• Knowledge of CMS regulations, corporate UR policies, and payer authorization strategies.