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Clinical Utilization Physician

2 months ago

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 hospital's utilization review committee, which aims to uphold high standards of healthcare quality while managing costs effectively. The Clinical Utilization Physician will perform clinical assessments on cases referred by case management and other healthcare professionals, aligning with the hospital's objectives for quality patient care.

Expectations for Houston Methodist Experience

Patient Demographics and Populations Served
Refer to departmental guidelines for details on primary age groups and populations served by this role.
Core Values
  • Deliver personalized care and service by consistently embodying our I CARE values:
    • INTEGRITY: We maintain honesty and ethical standards in all our actions.
    • COMPASSION: We consider the whole person, addressing emotional, ethical, physical, and spiritual needs.
    • ACCOUNTABILITY: We take responsibility for our actions.
    • RESPECT: We honor every individual as a person of worth and dignity.
    • EXCELLENCE: We strive for the highest standards in our work and serve as a model for others.
  • Adhere to the Caring and Serving Model
  • Provide exceptional service following Houston Methodist Service Standards
  • Ensure outstanding patient experiences by utilizing Positive Language principles
  • Collaborate intentionally with other healthcare professionals to facilitate strong communication and seamless experiences for patients and their families.
  • Engage patients in their care plans during shift reports as applicable
  • Embrace principles of cultural humility, diversity, equity, and inclusion
  • Support the organization's vision and mission while embodying the I CARE values
Key Responsibilities

Essential Functions for People
  • Engage with medical staff to discuss patient needs and alternative care levels. Provide guidance to case management on complex clinical matters and advise on next steps. Offer feedback to physicians regarding care levels, duration of stay, and quality concerns.
  • Lead the utilization review committee, actively contributing to the strategic objectives of the Utilization Management Program and serving as a liaison to other medical committees. Participate in evaluating and revising the hospital's Utilization Management Program annually.
  • Communicate with physicians to resolve delays and promote positive outcomes, ensuring accountability for efficient patient care management. Relay relevant findings regarding physician performance to medical staff leaders when necessary.
Essential Functions for Service
  • Develop strategies to enhance interdisciplinary efforts within the hospital and post-acute settings to optimize patient and family outcomes. Advocate for case management services and clinical documentation. Collaborate with medical staff to establish and measure performance standards related to patient care and resource utilization.
  • Conduct rounds on patient care units to identify opportunities for improving resource utilization and managing length of stay.
  • Support Clinical Documentation Specialists and Coders by addressing documentation challenges and providing guidance on compliance issues. Present findings based on quarterly trends in departmental meetings.
Essential Functions for Quality/Safety
  • Act as a consultant to attending physicians regarding the appropriateness of hospitalization, continued stay, and resource utilization. Utilize established criteria to document patient care reviews and decisions in accordance with hospital policies.
  • Review issues flagged by the case management department to ensure proper follow-up and recommend improvements as necessary.
  • Assess whether quality care standards, as defined by the hospital's Medical Executive Committee, are met.
  • Request additional clinical information from attending and consulting physicians as needed to make informed level of care determinations.
Essential Functions for Finance
  • Review medical records flagged by case managers or other healthcare team members to assist in managing denials. Provide recommendations related to resource utilization and service management.
  • Participate in the hospital's claim denial process, including responding to payer denials and determining the extent of appeals for denied cases.
Essential Functions for Growth/Innovation
  • Stay informed about current regulations, requirements, and guidelines related to case management, utilization review, and clinical documentation.
  • Provide ongoing education to physicians and other providers on the connection between clinical terminology and coding to enhance understanding of patient records and quality profiling.
  • Educate physicians and clinicians on regulatory requirements and appropriate utilization of resources. Facilitate referrals across the continuum of care.
This job description is not exhaustive; the employee may also perform other related duties as assigned. Houston Methodist reserves the right to modify job responsibilities as necessary.

Qualifications

Education
  • Graduate of an accredited medical school
Work Experience
  • A minimum of five years of recent clinical practice experience.
Licenses/Certifications

Required Licenses and Certifications
  • MD - Physician - Unrestricted medical license in the State of Texas AND
  • Active practitioner status
Knowledge, Skills, and Abilities

  • Demonstrates the necessary skills and competencies to perform the assigned job safely, as determined through ongoing assessments and evaluations.
  • Proficient in English, with the ability to communicate effectively with patients, physicians, and colleagues.
  • Ability to foster positive relationships with medical staff and collaborate effectively across healthcare disciplines.
  • Demonstrates a comprehensive understanding of utilization management, clinical documentation, and healthcare regulations.
Supplemental Requirements

Work Attire
  • Uniform No
  • Scrubs Yes
  • Business professional Yes
  • Other (department approved) No
On-Call*
*Employees may be required to be on-call during emergencies.
  • On Call* No
Travel**
**Travel requirements may vary by department.
  • May require travel within the Houston Metropolitan area Yes
  • May require travel outside Houston Metropolitan area No
Company Overview

Since its inception in 1919, Houston Methodist Hospital has gained international acclaim. It is affiliated with prestigious institutions and has been recognized multiple times for its excellence in healthcare. Houston Methodist Hospital invests significantly in research and innovation, providing state-of-the-art medical, surgical, and diagnostic services. With a large capacity and a dedicated workforce, it offers comprehensive care to patients globally.

The same high-quality care is available at several Emergency Care Centers in the region, equipped with advanced facilities for immediate medical attention.