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Healthcare Quality Consultant

2 months ago

Houston, Texas, United States Catholic Health Initiatives Full time

Overview

Catholic Health Initiatives is dedicated to enhancing the health of communities through a network of care facilities across the United States. With a commitment to compassion and service, we strive to support those in need and innovate in the delivery of healthcare services. Our mission is to ensure that quality care is accessible to all, particularly to the underserved populations.

Responsibilities

This position is remote, and candidates licensed in Texas are preferred. Other state licenses may be considered for future opportunities.

As the Clinical Utilization Advisor II, you will be responsible for conducting thorough clinical case evaluations as referred by case management and other healthcare professionals. Your role is crucial in ensuring compliance with regulatory standards while promoting effective patient care and resource utilization. You will collaborate with case management teams and healthcare professionals to review cases, provide care recommendations, and engage with medical staff and third-party payers regarding patient needs and alternative care options.

Key Responsibilities
  • Perform comprehensive medical record assessments to determine the necessity of inpatient admissions, the need for continued hospital stays, and the adequacy of discharge planning.
  • Possess a strong understanding of ICD-9-CM, ICD-10-CM/PCS, MS-DRG, APR-DRG, and the Medicare Inpatient Prospective Payment System (IPPS) to evaluate severity of illness and communicate effectively with treating physicians.
  • Act as a liaison between the national care management team and medical staff to foster cooperation and emphasize the importance of documentation.
  • Contribute to the dissemination of information regarding internal physician advisor services through hospital communications to enhance medical staff education.
  • Provide feedback on program outcomes to facility leadership, including Chief Medical Officers and Care Management Directors.
  • Deliver educational support to Care Management and Clinical Documentation Departments through effective communication and tracking for process improvement.
  • Participate in relevant facility committee meetings as needed, including Clinical Documentation Steering Committee and Utilization Review Committee.
  • Engage with attending physicians through direct communication to introduce referral services and new offerings.
  • Facilitate Peer to Peer discussions with payers and collaborate with operations to support clinical service utilization and revenue management.
Qualifications
  • MD or DO degree required.
  • A minimum of 3 years of experience as a Physician Advisor is required.
  • At least 5 years of experience in clinical practice is necessary.
  • Experience with Peer to Peer Reviews is essential.
  • Unrestricted medical license in one or more states, with a preference for Texas.
  • Comprehensive knowledge of clinical practices and regulations.
  • Established trust and respect among medical staff.
  • In-depth understanding of CMS regulations, including the 2-midnight rule.
  • Experience in utilization management.
  • Continuous education in quality and utilization management is preferred.
  • Strong communication skills in both written and verbal formats.

We offer a comprehensive benefits package that includes Medical/Dental/Vision coverage, FSA, Life Insurance, Short and Long-term Disability, 401k matching, Paid Time Off, and more.

#LI-Remote

Pay Range
$155.69 /hour