Clinical Utilization Specialist
2 weeks ago
The Clinical Utilization Specialist plays a pivotal role within the leadership framework of the healthcare facility, focusing on achieving the organization's objectives related to the efficient and effective use of medical services.
This role requires the development of in-depth knowledge regarding physician behavior patterns, resource utilization, medical necessity, documentation standards, care level transitions, denial management, and adherence to regulatory requirements and insurance agreements.
The Specialist is tasked with fostering and enhancing relationships with both the System Enterprise and the healthcare facility to optimize the utilization of Sutter Health's Internal Physician Advisor Services (IPAS).
Collaboration with medical staff, including residents and all utilization management (UM) personnel, as well as Care Management (CM) teams, is essential to create and implement strategies that enhance the use of hospital services.
This encompasses care management processes that ensure patients receive appropriate levels of care, supported by documentation that meets regulatory compliance and accurate coding.
The Clinical Utilization Specialist conducts clinical evaluations on cases referred by UM/CM staff or other healthcare professionals to fulfill regulatory standards in line with the hospital's goals for quality patient care and efficient healthcare service utilization.
Regular meetings with care management, UM staff, healthcare team members, and medical directors from third-party payers are part of the role to discuss patient needs and alternative care levels.
Additionally, the Specialist serves as a consultant and resource for attending physicians regarding the appropriateness of hospital admissions, continued stays, and resource utilization.
This position also acts as a liaison between Clinical Documentation Improvement (CDI) professionals, Health Information Management (HIM), and the hospital's medical staff to ensure accurate and complete documentation for coding and clinical data abstraction, capturing severity, acuity, and risk for mortality, as well as Direct Report Groups (DRG) assignment.
Qualifications:
Education:
Doctorate: Graduate of an accredited medical institution.
Licensure:
MD-Doctor of Medicine or DO-Doctor of Osteopathy with an unrestricted medical license in the state of residence.
Experience:
A minimum of 3 years of relevant experience in a similar role.
Skills and Knowledge:
- Exceptional interpersonal communication and negotiation abilities.
- Extensive knowledge of healthcare delivery and case management within a managed care context.
- Comprehensive understanding of Utilization Review, levels of care, and observation status.
- Familiarity with healthcare reimbursement systems, including HMO, PPO, and CMS Grouper.
Knowledge of post-acute care levels such as Home Health, Hospice, Advanced Illness Management (AIM), and Palliative Care, as well as Skilled Nursing Facility (SNF) and Long Term Acute Care (LTAC) is preferred.
- Proficient understanding of coding and DRG assignment processes is advantageous.
- Ability to effectively communicate and foster collaboration among patients, families, physicians, nurses, and other healthcare partners.
- Strong independent work ethic and sound judgment in interactions with physicians, payers, and patients.
- Commitment to service excellence in all interactions and responsibilities.
- Ability to manage time effectively and develop organized work processes in a dynamic environment with shifting priorities.
- Intermediate computer proficiency.
- Capacity to promote teamwork and function effectively within teams.
- Strong customer service skills that enhance the patient experience.
Job Shift:
Days
Schedule:
Full Time
Weekly Hours: 40
Position Status:
Exempt
Employee Status:
Regular
Number of Openings: 1
Compensation:
Pay Range is $127.05 to $203.28 / hour, with variations based on experience, education, skills, and other factors.
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