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Clinical Utilization Physician Consultant
2 months ago
Primary Objective:
The main duty of this role involves performing clinical evaluations on cases referred by Utilization Management personnel and/or other healthcare professionals, aligning with the organization's goals for the effective and efficient use of healthcare services and resources. This includes assessing the appropriate level of care, overseeing the suitable application of diagnostic and therapeutic procedures, and ensuring compliance with regulatory standards.
This position will provide support across all Aurora Health Care facilities during weekends.Key Responsibilities:
Conduct clinical evaluations as necessary on cases referred by Utilization Management staff and/or other healthcare professionals to guarantee high-quality patient care and the effective use of healthcare services, appropriate levels of care, while monitoring the correct application of diagnostic and therapeutic procedures.
Review cases to identify any potential delays in care delivery that may affect the transition to a lower level of care or prolong the length of stay.
Engage in discussions with Utilization Management/Case Management staff, site physician advisors, and/or attending physicians as required.Exhibit a thorough understanding of medical necessity criteria and ICD-10 regulations. Stay updated on federal, state, and payer regulatory and contractual obligations.
Collaborate with medical staff and other healthcare professionals regarding individual patient care plans and objectives within expected timelines and clinical pathways.
Licensure, Registration, and/or Certification Required:
A valid MD-DO license in Medicine and Surgery issued by the state where the professional practices.
Educational Qualifications:
Doctorate Degree in Medicine.
Experience Required:
Generally requires a minimum of 3 years of experience in clinical practice.
Experience in Clinical Documentation Improvement and Utilization Management as a member of the Utilization Management oversight committee or prior experience as a Physician Advisor is preferred. Certification as a Physician Advisor (CMPC, ACPA-C, CHCQM-PHYADV) is also preferred. Additional education in Quality, Utilization Management, and documentation improvement/integrity through continuing medical education programs and self-study is beneficial. Familiarity with national medical necessity criteria and ICD-10 coding guidelines is essential.
Knowledge, Skills & Abilities Required:
Demonstrates a solid understanding of medical necessity criteria.
Maintains current knowledge of federal, state, and payer regulatory and contractual requirements.
Possesses strong analytical and decision-making capabilities.
Must be self-motivated and possess leadership qualities, along with excellent interpersonal skills and effective communication abilities.
Ability to utilize electronic medical records and other digital tools for conducting reviews, analyzing data, and documenting as necessary for the role.
Basic computer skills with typing speed of 25-20 WPM preferred.Physical Requirements and Working Conditions:
Operates all necessary equipment to fulfill job responsibilities.
This job description outlines the general nature and level of work expected from the incumbent.
It is not intended to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the incumbent.
The incumbent may be required to perform other related duties.#J-18808-Ljbffr
