Department: Physician Advisor Services / Utilization Management

Reports to: Chief Utilization Officer (CUO)

Direct Reports: Henry Ford Health Physician Advisors (system-wide)

FLSA Status: Exempt | Employment Type: Part-Time

General Summary

The Medical Director of Internal Physician Advisor Services (IPAS) leads a centralized, system-wide physician advisor service that ensures accurate patient status determinations, timely peer-to-peer (P2P) reviews, effective secondary clinical reviews, and proactive denial prevention. This position collaborates closely with operational and revenue cycle leadership to optimize utilization, reduce avoidable days, and support documentation that reflects true acuity—improving both patient outcomes and financial performance across Henry Ford Health.

Essential Functions / Key Responsibilities

Service Leadership & Operations

·         Build, scale, and standardize a centralized IPAS model covering secondary admission reviews, observation vs. inpatient status determinations, long-stay oversight, and P2P reviews across all hospitals/markets.

·         Define service hours, coverage model, and escalation pathways to ensure every feasible P2P is completed within payer timeframes, with strong overturn performance.

·         Establish policies, procedures, decision trees, and standardized workflows for UR/UM nurse reviews and physician advisor engagement.

·         Create a staffing plan (FTEs, skills mix, onboarding), and manage schedules, productivity expectations, and after-hours/on-call coverage as needed.

Clinical Review Excellence & Denial Prevention

·         Drive first-pass accuracy for patient status determinations (inpatient vs. observation) through real-time secondary reviews and provider education.

·         Lead strategies to prevent medical-necessity and status-related denials; partner with Denials/Appeals teams to analyze root causes and implement corrective actions.

·         Ensure clear, defensible clinical rationale documentation for secondary reviews and P2Ps; maintain payer-specific medical policy expertise (CMS/MA/commercial) and InterQual/MCG criteria proficiency.

·         Support audit readiness and consistency of responses to pre-payment and post-payment reviews, including complex payer or regulatory audits.

Collaboration & Physician Engagement

·         Serve as the clinical escalation resource for complex status determinations; partner with hospital leadership to optimize long stay OBS rate and reduce avoidable days.

·         Provide targeted education to attending physicians, hospitalists, and APPs on documentation supporting medical necessity and level of care; promote standardized terminology and evidence-based criteria.

·         Coordinate with Quality/CDI to align documentation with acuity and quality outcomes (SOI/ROM) while keeping clear role boundaries between CDI education and status review functions.

Data, Analytics & Performance Management

·         Develop dashboards and scorecards that track initial status accuracy, P2P completion & overturn rates, denial rates, appeal success, long stay OBS rate, and avoidable days.

·         Review performance with hospital and system leadership; run cohort and payer-specific analyses to identify opportunities and validate interventions.

·         Use baseline/retrospective reviews to inform strategy; lead continuous improvement cycles (PDSA) and close performance gaps across sites.

Governance, Compliance & Accreditation

·         Ensure adherence to CMS, Medicare Advantage, and commercial payer requirements for medical necessity and patient status.

·         Align IPAS policies with Joint Commission/NCQA standards and Henry Ford Health compliance frameworks; participate in UR Plan governance and policy updates.

·         Maintain consistent documentation practices and audit readiness; coordinate with Compliance and Legal on complex cases.

Talent Management (Direct Reports: HFH Physician Advisors)

·         Recruit, hire, onboard, mentor, and evaluate Henry Ford Health Physician Advisors; establish competencies, continuing education, and professional development pathways.

·         Set clear goals, productivity standards, and accountability mechanisms; conduct regular performance reviews and provide coaching.

·         Plan coverage models and succession for critical functions; foster an inclusive, high-performance culture focused on service, quality, and compliance.

External Partnerships & Stakeholder Relations

·         Maintain constructive relationships with payer medical directors and utilization reviewers to improve P2P throughput and overturn rates.

·         Coordinate with external audit entities and selected strategic partners supporting baseline assessment, process discovery, or operational improvements.

·         Represent IPAS in system committees, cross-functional workgroups, and executive forums.

Key Performance Indicators (KPIs)

·         P2P completion rate and P2P overturn rate (payer-specific, time-bound)

·         Initial status accuracy (% correct first-pass inpatient vs. observation)

·         Denial rate reduction (medical necessity/status/documentation) and appeal success rate

·         Long stay OBS rate and avoidable days improvement

·         Timeliness: average time to secondary review; secondary review turnaround time

·         Documentation/quality alignment in partnership with CDI/Quality (e.g., CMI, SOI/ROM capture; selected Vizient expected performance measures)

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