Clinical Utilization Consultant

2 weeks ago


Houston, Texas, United States Houston Methodist Full time

Position Overview
The Clinical Utilization Consultant at Houston Methodist plays a pivotal role in guiding the case management team, clinical documentation experts, and medical personnel on issues related to medical necessity, compliance standards, and effective resource utilization.

Key Responsibilities
As a vital member of the hospital's utilization management committee, the consultant is tasked with:

  • Leading discussions with medical staff to address patient needs and alternative care options.
  • Providing expert consultation to case management regarding intricate clinical matters and advising on subsequent actions.
  • Offering constructive feedback to physicians concerning care levels, patient stay durations, and quality of service.
  • Chairs the utilization management committee, contributing to the establishment of strategic objectives for the Utilization Management Program.
  • Assisting in the evaluation and enhancement of the hospital's Utilization Management Program, including the annual review of the UR plan.

Quality and Safety Functions
The consultant will act as a resource for attending physicians, ensuring decisions regarding hospitalization appropriateness and resource usage align with quality care standards. Responsibilities include:

  • Utilizing established criteria to document patient care assessments and decisions.
  • Reviewing issues flagged by case management to ensure appropriate follow-up and recommending necessary improvements.
  • Engaging with physicians to gather additional clinical information for effective care level determinations.

Financial Oversight
In this role, the consultant will also be involved in:

  • Reviewing medical records to assist in identifying and managing claim denials.
  • Participating in the claims denial process, including drafting responses and determining appeal strategies.

Professional Development
The Clinical Utilization Consultant will maintain up-to-date knowledge of relevant regulations and guidelines, providing ongoing education to medical staff on:

  • The relationship between clinical documentation and reimbursement.
  • Regulatory requirements and optimal resource utilization.

This position encompasses a variety of responsibilities aimed at enhancing patient care quality and operational efficiency within the healthcare setting.



  • Houston, Texas, United States Houston Methodist Hospital Full time

    Position Overview: The Clinical Utilization Advisor at Houston Methodist plays a pivotal role in guiding the case management team, clinical documentation experts, and medical personnel on critical issues surrounding medical necessity and compliance regulations. This position fosters collaboration with payers and assesses physician practice patterns to...


  • Houston, Texas, United States Houston Methodist Full time

    Position Overview At Houston Methodist, the Clinical Utilization Physician plays a pivotal role in guiding, consulting, and advising the case management team, clinical documentation specialists, medical staff, and the hospital on issues related to medical necessity, compliance regulations, and collaboration with payers. This position is integral to the...


  • Houston, Texas, United States Houston Methodist Hospital Full time

    Position Overview:At Houston Methodist, the Clinical Practice Consultant role acts as a key advisor and expert clinician within a designated service line or specialty area, operating at the highest level of clinical practice.Key Responsibilities:This position is responsible for providing education and professional development to nursing staff while being...


  • Houston, Texas, United States Infosys Consulting Full time

    Lead Consultant – Organizational Change in UtilitiesInfosys Consulting is at the forefront of driving transformation in the Utilities Sector, seeking seasoned and innovative Organizational Change and Learning Lead Consultants. This pivotal role encompasses the entire utilities value chain, from generation and transmission to distribution and customer...


  • Houston, Texas, United States Catholic Health Initiatives Full time

    OverviewCatholic Health Initiatives is dedicated to fostering healthy communities through compassionate care. With a vast network of care facilities across the United States, we are committed to serving those in need, particularly the vulnerable populations. Our mission emphasizes innovation in healthcare delivery, ensuring that quality care is accessible to...


  • Houston, Texas, United States Harris Health System Full time

    Position OverviewThe Pharmacy Utilization Clinical Supervisor will manage the effective and efficient application of pharmaceuticals within the Pharmacy Division. The primary objective of this role is to enhance the quality of care, cost-efficiency, and clinical outcomes through the utilization of approved medications on the formulary, ensuring adherence to...


  • Houston, Texas, United States SBKC Management Full time

    Clinical Nutrition Consultant Position at SBKC ManagementThe Clinical Nutrition Consultant role focuses on performing thorough nutritional evaluations, crafting personalized dietary strategies, delivering education and support to patients, and collaborating with medical teams to ensure the highest standard of patient care.Independently assesses, formulates,...


  • Houston, Texas, United States United Imaging North America Full time

    Job OverviewAbout Us:United Imaging is a prominent global innovator in medical devices, offering a comprehensive range of advanced healthcare products, digital solutions, and intelligent systems that encompass the full spectrum of imaging diagnostics and treatment. Our North American headquarters is located in Houston, where we are committed to enhancing our...


  • Houston, Texas, United States Houston Methodist Hospital Full time

    Job SummaryHouston Methodist Hospital is seeking a highly skilled Physician Consultant to join our team. As a key member of our clinical leadership team, the Physician Consultant will play a critical role in ensuring the highest quality of patient care and optimizing resource utilization.Key ResponsibilitiesCollaborate with medical staff to develop and...


  • Houston, Texas, United States DM Clinical Research Full time

    Position OverviewThe Clinical Trials Laboratory Specialist plays a pivotal role in executing specialized laboratory tasks for clinical research, utilizing advanced laboratory techniques. This includes, but is not limited to, the routine extraction of peripheral blood mononuclear cells (PBMC), conducting flow cytometry, and isolating DNA/RNA, while adhering...


  • Houston, Texas, United States DM Clinical Research Full time

    Job OverviewThe Clinical Training Coordinator II (Travel) plays a crucial role in ensuring that high-quality research is conducted at designated investigative sites, adhering to sponsor protocols, FDA regulations, and ICH/GCP guidelines. This position is essential for delivering superior quality data to sponsors and enhancing the performance and skills of...


  • Houston, Texas, United States Regency Integrated Health Services Full time

    Position Overview The Clinical Specialist at Regency Integrated Health Services plays a crucial role in enhancing the quality of care provided to residents. This position involves serving as a knowledgeable advisor, educator, and auditor, while collaborating closely with the facility's leadership team, including the Administrator and Director of Nursing....

  • Clinical Advisor

    5 days ago


    Houston, Texas, United States Houston Methodist Hospital Full time

    Job SummaryHouston Methodist Hospital is seeking a highly skilled Physician Consultant to join our team. As a key member of our clinical leadership team, the Physician Consultant will play a critical role in ensuring the highest quality of patient care and optimizing resource utilization.Key ResponsibilitiesCollaborate with medical staff to develop and...


  • Houston, Texas, United States BGE College Recruiting Full time

    BGE, Inc. is a prominent consulting firm operating nationwide, offering a wide range of services in civil engineering, planning, landscape architecture, construction management, surveying, and environmental consulting for both public and private sector clients. Our team members benefit from a comprehensive benefits package that includes exceptional...


  • Houston, Texas, United States BGE, Inc. Full time

    BGE, Inc. is a prominent consulting firm operating nationwide, specializing in civil engineering, planning, landscape architecture, construction management, surveying, and environmental services for both public and private sector clients. Our team members benefit from a comprehensive benefits package that includes exceptional healthcare, a generous 401(k)...


  • Houston, Texas, United States BGE College Recruiting Full time

    BGE College Recruiting is a prominent consulting firm that specializes in civil engineering, planning, landscape architecture, construction oversight, surveying, and environmental services for both public and private sector clients. Our team members benefit from a comprehensive package that includes exceptional healthcare, a generous 401(k) match, career...


  • Houston, Texas, United States DM Clinical Research Full time

    Job OverviewPosition Summary:A Study Manager plays a crucial role in ensuring that high-quality research is executed at designated investigative sites, adhering to sponsor protocols, FDA regulations, and ICH/GCP guidelines. The objective is to deliver the highest quality data to the sponsor while meeting or exceeding enrollment expectations and achieving...


  • Houston, Texas, United States BGE, Inc. Full time

    BGE, Inc. is a prominent consulting firm operating nationwide, offering expertise in civil engineering, planning, landscape architecture, construction management, surveying, and environmental services for both public and private sector clients. Our team members benefit from a comprehensive package that includes exceptional healthcare, a generous 401(k)...


  • Houston, Texas, United States BGE, Inc. Full time

    BGE, Inc. is a prominent consulting firm operating nationwide, specializing in civil engineering, planning, landscape architecture, construction management, surveying, and environmental services for both public and private sector clients. Our team members benefit from a comprehensive package that includes exceptional healthcare, a generous 401(k) matching...


  • Houston, Texas, United States CommonSpirit Health Full time

    Overview:Relocation assistance available up to $10,000CommonSpirit Health is a prominent healthcare organization committed to providing exceptional care across various settings. Our mission is to foster healthy communities and advocate for those in need. We operate numerous facilities, including hospitals and clinics, ensuring that our services are...