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Clinical Utilization Management Advisor
2 months ago
Position Overview
The Clinical Utilization Management Advisor (CUMA) serves as a vital link among hospital administration, clinical personnel, and support teams. This role encompasses part-time inpatient duties in utilization management and care coordination while also maintaining a portion of inpatient patient care responsibilities. The expectation is for the CUMA role to operate at a dedicated .40 FTE. In this capacity, the CUMA is anticipated to engage regularly with the Senior Director of Care Management and other healthcare team members to review selected cases and provide recommendations for patient care.
Key Responsibilities
- Collaborates closely with the Senior Director of Care Management to ensure a balance between advocacy for patients and families, and the operational needs of the organization.
- Conducts thorough clinical evaluations on cases referred by care management staff or other healthcare professionals to comply with regulatory standards and hospital objectives aimed at ensuring quality patient care and efficient utilization of healthcare resources.
- Serves as the associate chair of the utilization management committee, supporting the chair in advancing quality, safety, performance metrics, and financial objectives.
- Assists care management teams with patient transfer requirements to alternative care levels when necessary.
- Demonstrates excellent and timely communication follow-up among patients, families, care managers, physicians, and payors.
- Utilizes current utilization management software for informed decision-making regarding patient admissions or observation statuses.
- Collaborates with care management for cases that do not meet current admission criteria and documents discussions with physicians as required.
- Facilitates peer-to-peer discussions and opportunities for clinical documentation.
- Assists in mediating between various departments, teams, or individuals involved in the patient's care episode when necessary.
- Provides education to medical and professional staff regarding DRG LOS, denials, clinical documentation, practice guidelines within the EMR, and any regulatory updates.
- Maintains up-to-date knowledge of regulatory and practice changes relevant to the physician advisor role.
- Undertakes additional duties and projects as assigned.
Qualifications
A. Education
- Completion of an MD or DO accredited residency program.
B. Experience
- A minimum of four (4) years in a healthcare setting, preferably in a managed care environment with Hospitalist experience.
- At least five (5) years of clinical practice experience post-residency or fellowship training.
- Experience in identifying best practices, clinical utilization, and care management is preferred.
- Possession of an active and unrestricted medical license in the State of California.
- Board certification in a specialty recognized by the American Board of Medical Specialties (ABMS).
- Currently engaged in a patient care role as a hospitalist, emergency medicine physician, intensivist, anesthesiologist, or surgical/medical specialist.
C. Skills and Knowledge
- Ability to prioritize and efficiently resolve critical issues.
- Strong analytical and technical skills related to data management, analysis, and presentation.
- Proficient in Microsoft applications including Word, Advanced Excel, and PowerPoint.
- Excellent oral and written communication skills.
- Capable of delivering presentations to diverse audiences.
- Skilled in planning and facilitating meetings and workgroups.
- Exceptional organizational skills and attention to detail, with the ability to manage multiple tasks and meet deadlines.
- High initiative and ability to work collaboratively as part of a team.
- Adept at building effective relationships with a diverse range of individuals, including management and clinical experts.
