It's more than a career, it's a calling.
MO-SSM Health Mission Hill
Worker Type:
Regular
Job Summary:
Provides enterprise physician leadership across utilization management, clinical documentation integrity, and denial prevention to ensure care delivered is medically necessary, accurately documented, and defensible. Serves as the system physician advisor, aligning clinical decision making with regulatory, payer, and documentation requirements while supporting physicians, Clinical Documentation Integrity (CDI), and care coordination teams to reduce denials and revenue leakage.
Job Responsibilities and Requirements:
PRIMARY RESPONSIBILITIES
- Provides enterprise physician leadership for utilization management (UM), medical necessity, and level‑of‑care determinations, ensuring consistent, compliant decision‑making across regions.
- Serves as the system physician advisor, supporting and guiding physicians, care coordination, and leadership on complex clinical, regulatory, and payer‑related questions.
- Acts as the physician champion for Clinical Documentation Integrity (CDI), partnering with CDI and coding to ensure documentation accurately reflects clinical severity, complexity, and resource utilization.
- Leads clinical validation strategy for denials, including Diagnosis-Related Group (DRG) downgrades and medical necessity disputes, ensuring defensible clinical rationale aligned with payer and regulatory standards.
- Oversees and standardizes physician advisement workflows, escalation criteria, and best practices across regions to reduce variation and duplication of effort.
- Collaborates closely with care coordination, UM, CDI, coding, revenue integrity, and managed care teams to align clinical decision‑making with operational and financial goals.
- Analyzes denial trends, utilization patterns, and documentation gaps at the system level, identifying root causes and preventive opportunities rather than isolated case fixes.
- Provides physician‑to‑physician education and coaching focused on medical necessity, documentation quality, and defensibility, especially for high‑impact service lines or payer risk areas.
- Supports development and optimization of Epic workflows, data integrations, and reporting related to utilization review, physician advisor activity, and denial prevention.
- Serves as a key physician leader in governance, performance oversight, and strategic planning related to care coordination, physician advisement, and denial prevention initiatives.
- Works in a constant state of alertness and safe manner.
- Performs other duties as assigned.
EDUCATION
- Medical degree (MD or DO) with current licensure to practice medicine in the State
EXPERIENCE
- Five years of healthcare experience, with two years' experience in healthcare administration; project work, physician advisor work or CDI work
Work Shift:
Day Shift (United States of America)
Employee
Department:
8740000033 Chief Nursing Officer
Scheduled Weekly Hours:
40
Benefits:
SSM Health values our exceptional employees by offering a comprehensive benefits package to fit their needs.
Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).
Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.
Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members.
Explore All Benefits
SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity,pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.
