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Clinical Utilization Advisor
2 months ago
Overview:
The Clinical Utilization Advisor is a pivotal full-time administrative role at CHRISTUS Health, dedicated to enhancing patient care through strategic guidance and collaboration. This position involves educating, consulting, and advising both the Care Management Department and the medical staff on critical aspects such as physician practice patterns, documentation standards, resource utilization, medical necessity, compliance regulations, and fostering relationships with payers and the community.
The Advisor plays a crucial role in ensuring physician engagement and adherence to the initiatives set forth by the Care Management and Clinical Documentation Improvement (CDI) Departments. This includes advocating for effective physician documentation to accurately reflect the patient's Level of Care (LOC), billing status, and the appropriateness of Medicare Severity-Diagnosis Related Group (MS-DRG)/DRG assignments.
The Advisor will maintain monthly records detailing the time dedicated to the responsibilities outlined below. Standard work hours are Monday through Friday, with no on-call duties.Qualifications:
The Clinical Utilization Advisor role is best suited for a physician with the following credentials:
- Minimum of 5 years of clinical experience
- Licensed physician in the state of practice
- Board certified in a relevant clinical specialty
- Certification from the American Board of Quality Assurance and Utilization Review Physicians, Inc (ABQUARP) is preferred
- Experience in clinical practice with a solid understanding of utilization review processes
- Experience serving on or leading a Utilization Management Committee
- Proven track record of cost-effective practice
- Responsibilities of the Clinical Utilization Advisor
- Collaborate with the Director of Care Management to lead the Utilization Review Committee
- Monitor key performance metrics for Utilization Management and engage in action plans to meet targets.
Key Metrics Include:
- Trends in denials, appeals, and recoveries
- Length of stay for inpatient and observation cases
- Condition Code 44
- Deliver educational sessions to physicians and clinicians on regulatory requirements, appropriate billing statuses, and utilization of alternative care levels, community resources, and end-of-life care.
- Assist physicians in facilitating referrals within the continuum of care
- Mentor and educate physicians on payer requirements
- Provide coaching to Utilization Review Case Managers to enhance their knowledge in care progression
- Inform physicians about the significance of clinical documentation programs and collaboration with CDI specialists
- Engage in daily Interdisciplinary Rounds (IDRs) to expedite testing and treatment, ensuring appropriate patient care and LOC.
- Guide Emergency Department Physicians and Care Management staff to ensure accurate LOC designation at patient intake.
- Act as a liaison with payers to facilitate approvals and mitigate denials or carved-out days when necessary.
- Review long-stay patients escalated from Care Management to determine the most suitable LOC.
- Assess cases requiring a hospital notice of non-coverage determination and discuss with the attending physician.
- Document patient care reviews, decisions, and relevant information in accordance with hospital policy.
- Possess foundational knowledge of InterQual and MCG criteria.
- Participate in Care Management leadership and staff meetings to identify and advance departmental goals.
- Notify the Care Manager of any conflicts of interest in reviewing specific patient records and assist in identifying a physician for such reviews.
- Provide constructive feedback to physicians on clinical documentation using specific case examples.
Benefits:
- Balanced work-life integration
- Competitive salary and benefits package
- Relocation assistance available
Community Overview:
- Convenient access to major urban areas
- Proximity to local transportation options
- Year-round outdoor recreational activities available
- Access to quality public and private educational institutions
Work Type:
Full Time
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