Clinical Utilization Consultant
2 weeks ago
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.
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