Medical Director - Physician Advisor, Utilization Management At
City of Hope, we're redefining the future of cancer treatment through innovation, collaboration, and compassionate care. As one of the nation's leading comprehensive cancer centers, we're seeking an experienced and collaborative
Medical Director - Physician Advisor, Utilization Management to serve as a trusted physician leader dedicated to advancing quality, patient care, and operational excellence across our health system.
This is an exceptional opportunity for a physician who is passionate about improving care delivery, partnering with multidisciplinary teams, and driving strategic initiatives that enhance patient outcomes, optimize resource utilization, and support the financial integrity of a world-class academic healthcare organization.
Position Summary The Medical Director - Physician Advisor serves as a key clinical and administrative leader responsible for advancing care progression, utilization management, clinical documentation integrity (CDI), and regulatory compliance across City of Hope. Working closely with physicians, nursing leadership, case management, revenue cycle, quality, and executive leadership, this role ensures patients receive the appropriate level of care at the appropriate time while promoting efficient patient throughput and exceptional clinical outcomes.
The Physician Advisor plays an integral role in optimizing patient flow and length of stay (LOS) through active participation in multidisciplinary rounds, complex case consultation, admission status determinations, and discharge planning. By partnering with physicians and care teams, this leader provides expert guidance on medical necessity, payer requirements, documentation best practices, and regulatory standards to support high-quality, patient-centered care.
In addition, the Medical Director leads utilization management activities, including secondary reviews for admission status, Two-Midnight Rule compliance, complex admission determinations, continued stay reviews, and escalation of challenging utilization management cases. The role provides oversight of high-risk accounts through Epic work queues, reviews HINN cases as appropriate, and collaborates with interdisciplinary teams to ensure compliance with CMS regulations, accreditation standards, and payer guidelines.
As a strategic physician leader, the Medical Director also serves as a valued partner in payer Joint Operating Committees (JOCs), contracting discussions, quality improvement initiatives, CC44 determinations, and denials prevention efforts. This role works closely with Clinical Documentation Integrity (CDI) and Revenue Cycle teams to strengthen documentation quality, improve coding accuracy, reduce avoidable denials, and optimize reimbursement while maintaining the highest standards of clinical excellence.
The Medical Director will also provide physician advisory support for Clinical Documentation Integrity (CDI) initiatives and denials management, offering expert clinical guidance on documentation improvement, appeal strategies, and complex payer disputes.
As a successful candidate, you will: - Provide physician leadership for care progression, utilization management, and clinical documentation initiatives across the organization.
- Collaborate with physicians, case management, nursing, and multidisciplinary care teams to optimize patient flow, improve care progression, and reduce unnecessary length of stay (LOS).
- Perform secondary utilization reviews, admission status determinations, continued stay reviews, and Two-Midnight Rule evaluations to ensure appropriate patient status and medical necessity.
- Serve as the physician resource for complex medical necessity determinations, payer requirements, CMS regulations, and accreditation standards.
- Review high-risk utilization management work queues, HINN cases, CC44 determinations, and other complex cases requiring physician-level review.
- Partner with Clinical Documentation Integrity (CDI) specialists to improve physician documentation, coding accuracy, and clinical specificity that supports quality outcomes and appropriate reimbursement.
- Lead physician education initiatives on documentation best practices, medical necessity, utilization management principles, payer expectations, CMS regulations, and evolving regulatory requirements.
- Conduct retrospective and concurrent chart reviews to identify documentation opportunities, utilization trends, and areas for clinical and operational improvement.
- Analyze denial data, utilization metrics, and physician documentation trends to identify root causes, develop targeted action plans, and implement sustainable process improvements that reduce denials and improve organizational performance.
- Partner with Revenue Cycle, CDI, Case Management, Quality, and Operational leaders to develop strategies that strengthen documentation, improve utilization performance, and optimize reimbursement.
- Support denials prevention, peer-to-peer reviews, and appeals by providing physician-to-physician consultation and clinical expertise.
- Participate in payer Joint Operating Committees (JOCs), contracting discussions, quality improvement initiatives, and interdisciplinary committees to advance organizational goals.
- Lead and support physician chart auditing initiatives to ensure documentation accuracy, compliance with regulatory and payer requirements, and adherence to organizational standards.
- Monitor organizational performance related to utilization management, denial rates, documentation quality, and care progression, using data analytics to drive continuous quality improvement.
- Champion a culture of compliance by ensuring physician practices consistently align with CMS Conditions of Participation, federal and state regulations, accreditation standards, and payer policies.
- Serve as a trusted advisor and collaborative partner to physicians, clinical leaders, and executive leadership, fostering a culture of accountability, continuous improvement, and patient-centered care.
Your qualifications should include:- Medical Doctor
- Active member of a Medical Staff with at least 7 years' experience with 5 years in a leadership capacity.
- Expertise in utilization management, state/federal regulations, private payer contracts.
Required Courses/Training: Completion of City of Hope required onboarding and compliance training
- MD or DO license in California
Preferred Education: - Master's in Business Administration
Preferred Experience: - Hospitalist or oncology experience
- Dedication to quality, safety, efficiency, satisfaction, and cost reduction.
- Familiarity with inpatient and outpatient payer requirements
- Propensity for teaching others
Skills/Abilities: - Broad range of medical/clinical knowledge with experience in oncology
- A good communicator with strong interpersonal skills.
- Willing and able to have "difficult conversations" with physicians.
- Ability to work with front-line staff and executive leadership.
- Electronic Health Record (EHR) Systems - EPIC
- InterQual by Optum
- Microsoft Office or equivalent productivity tools.
