Clinical Utilization Specialist
2 weeks ago
The Clinical Utilization Specialist is an integral part of the leadership team, focused on achieving the organization's objectives for the effective and efficient use of healthcare services.
This role involves developing a deep understanding of physician practice patterns, resource utilization, medical necessity, and compliance with regulatory standards.
The Specialist will work collaboratively with medical staff and utilization management teams to enhance the use of hospital services, ensuring that patients receive appropriate levels of care supported by accurate documentation.
Key Responsibilities:
- Conduct clinical reviews of cases referred by utilization management and care management staff.
- Consult with attending physicians regarding hospitalization appropriateness and resource utilization.
- Act as a liaison between clinical documentation improvement professionals and medical staff to ensure accurate coding and documentation.
- Engage with care management and medical directors of third-party payers to discuss patient needs and alternative care levels.
Qualifications:
Education:
Doctorate from an accredited medical institution.
Certification & Licensure:
MD or DO with an unrestricted medical license in the state of residence.
Experience:
A minimum of three years of relevant experience in a healthcare setting.
Skills:
Strong interpersonal communication and negotiation skills.
Comprehensive knowledge of healthcare delivery systems and case management.
Familiarity with utilization review processes and healthcare reimbursement systems.
Ability to work independently while promoting collaboration among healthcare teams.
Job Shift:
Days
Schedule:
Full Time, 40 hours per week, Monday to Friday.
Benefits:
Comprehensive benefits package available.
Position Status:
Exempt
Sutter Health is an equal opportunity employer. Pay range is competitive and based on experience and qualifications.
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