Medical Director Physician Advisors - UNCH Utilization Management Administration

Description

Job Summary:
The Medical Director for Utilization Management provides strategic and operational oversight for the denial functions of the System Enterprise Services (SES) Physician Advisor program. This role supports appropriate reimbursement for high-quality, cost-effective, and safe patient care by aligning with regulatory, professional, and organizational standards, in coordination with the Mid-Cycle Revenue Operations System Enterprise Services Division and the System Executive Medical Director for Physician Advisors.

The Medical Director for Physician Advisors is responsible for program development, training, scheduling, and management of physicians within the Physician Advisor denials program across all SES entities. The Medical Director for Utilization Management provides clinical denials support for medical necessity and level of care while helping ensure compliant reimbursement. This position plays a vital role in facilitating intradepartmental collaboration, supporting appeal nurses to function at the level their license expects in their SES roles, and driving continuous improvement in operational performance. Key responsibilities include serving as a clinical and denials resource for appeal nurses, triaging cases for legal escalation, and participation in ALJ and arbitration hearings as an expert witness. The Medical Director also actively trains peer advisors on all related functions. This role plays a central part in monitoring work queues associated with physician advisor denial activities and other assigned projects.

Description of Job Responsibilities:
Reporting to the SES Executive Medical Director for Physician Advisor Services, the SES Medical Director for Utilization Management provides enterprise-wide leadership and strategic direction for the Physician Advisor denials function across the System Enterprise Services (SES) hospitals. This includes oversight of physician scheduling, training, performance management, and professional development of physician advisor denial functions within the advisor team. The role ensures that SES receives appropriate reimbursement for the delivery of safe, high-quality, and cost-effective care.

The Medical Director collaborates closely with Utilization Management, and SES/Executive Physician leadership to ensure inappropriate denials are appealed timely to the fullest extent supported by the clinical documentation. This includes providing feedback to Physician Advisor Front End functions to proactively prevent inappropriate denials from occurring where possible. The Medical Director interfaces with third-party payers as needed, and consults with attending physicians to support accurate documentation and service justification.

Key functions of the role include supporting clinical denial nurses, leveraging AI to enhance efficiency while also ensuring accuracy and compliance, understanding legal and regulatory protections to combat "industry standard" payor practices, supporting managed care contracting with payor feedback and recommendations, and serving as a subject matter expert in legal denial escalations.

This role also plays a central part in evaluating utilization and quality data, working with SES and Executive Physician leaders to implement corrective actions or strategic improvements. The Medical Director provides regular updates to the System Executive Medical Director of Physician Advisor Services, contributes to Utilization Review, Denial, and Audit Committee meetings, and co-chairs SES entity Utilization Management Committee meetings.

In collaboration with other Revenue Cycle teams and when requested by the SES Executive Physician Advisor Services, the Medical Director helps decrease preventable write-offs, helps identify opportunities for margin improvement, and other related projects when needed. This includes leading education sessions, coaching physicians, and mentoring the physician advisor denial team. The role also shares actionable data on trends in resource utilization using these insights to drive targeted improvements across the health system.

This role may include staffing peer-to-peer shifts, denials management shifts, and other Physician Advisor-related duties based on SES needs.

Education Requirements:
Graduate of an accredited school of medicine

Licensure/Certification Requirements:
Board certified/eligible physician licensed in the state of NC

Professional Experience Requirements: Requires at least 10 years of inpatient physician experience with at least five years of Physician Advisor experience.

Knowledge, Skills, and Abilities Requirements:

• Possesses strong knowledge of utilization management rules and regulations across lines of business
• Exceptional relationship building and networking skills
• Outstanding communication skills; can express opinions openly and non-defensively
• Strong work ethic, unquestionable integrity and character
• Approachable, flexible, and adaptable to change
• Strong attention to detail and accuracy; excellent organizational skills

Contact - Laura.Oakes@unchealth.unc.edu

Legal Employer: NCHEALTH
Entity: Shared Services
Organization Unit: System Care Management
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Assignment Type: Onsite
Work Schedule: Day Job
Location of Job: US:NC:Morrisville
Exempt From Overtime: Exempt: Yes

This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position.

Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.

UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.