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Clinical Utilization Advisor

2 months ago

Houston, Texas, United States Catholic Health Initiatives Full time

Overview

Catholic 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 all.

Key Responsibilities

This position is remote, and preference will be given to candidates licensed in Texas. Other state licenses may be considered for future opportunities.

As a Clinical Utilization Advisor II, you will be responsible for conducting thorough clinical assessments as referred by case management and other healthcare professionals. Your role will ensure compliance with regulatory standards while promoting high-quality patient care and efficient healthcare service utilization. You will collaborate with case management teams and healthcare professionals to review cases, providing recommendations for patient care and engaging with medical staff and third-party payers regarding patient needs and alternative care options.

Essential Duties
  • Perform comprehensive medical record evaluations to determine the necessity of inpatient admissions, the need for continued hospital stays, and the effectiveness of discharge planning.
  • Utilize knowledge of ICD-9-CM, ICD-10-CM/PCS, MS-DRG, APR-DRG, and the Medicare Inpatient Prospective Payment System (IPPS) to assess severity of illness and communicate effectively with treating physicians.
  • Act as a liaison between the national care management team and medical staff to enhance understanding of documentation practices.
  • Facilitate communication of internal physician advisor services through hospital newsletters and other channels to educate medical staff.
  • Provide feedback on program outcomes to facility leadership, including Chief Medical Officers and Care Management Directors.
  • Deliver education and constructive feedback to Care Management and Clinical Documentation Departments to support process improvement initiatives.
  • Participate in relevant facility committee meetings as needed, including Clinical Documentation Steering Committee and Utilization Review Committee.
  • Engage with attending physicians through face-to-face and electronic communications to introduce referral services and new offerings.
  • Conduct Peer-to-Peer discussions with payers as necessary, coordinating with operations to support physicians and attending relevant committee meetings.
Qualifications
  • MD or DO degree required.
  • A minimum of 3 years of experience as a Physician Advisor is essential.
  • At least 5 years of clinical practice experience is required.
  • Experience in conducting Peer-to-Peer Reviews is necessary.
  • Unrestricted medical license in one or more states, with Texas preferred.
  • Comprehensive knowledge of clinical practices and respect from medical staff.
  • In-depth understanding of CMS regulations, including the 2-midnight rule.
  • Experience in utilization management is essential.
  • Commitment to ongoing education in quality and utilization management.
  • Proficient in business English, with strong written and verbal communication skills.

We offer a comprehensive benefits package that includes Medical/Dental/Vision coverage, Flexible Spending Accounts, Life Insurance, Short and Long-term Disability, 401k matching, Paid Time Off, Wellness Programs, Tuition Reimbursement, and more.

#LI-Remote

Pay Range
$155.69 /hour