Clinical Utilization Advisor

1 week ago


York, Pennsylvania, United States WellSpan Health Full time

Clinical Utilization Advisor

Location: WellSpan Medical Group

Schedule: PRN/Per Diem

Sign-On Bonus: Eligible

Work Arrangement: Remote/Hybrid

Position Type: Regular

Overview:

The Clinical Utilization Advisor plays a pivotal role in overseeing case management and utilization review functions conducted by the WellSpan Case Management team.

Key Responsibilities:

  • Make utilization management decisions in compliance with applicable regulations, facilitating communication between healthcare providers and insurance entities.
  • Enhance collaboration with health plans and payers to ensure effective population management aligned with contractual obligations.
  • Participate in monthly Utilization Review meetings, identifying cases for discussion and contributing to agenda setting.
  • Support Population Health initiatives, including ACO development and medical home strategies, as directed by the Medical Director.
  • Act as a liaison between physician advisors and the Medical Director of Corporate Case Management.
  • Engage in daily huddles to address complex cases, reinforce policies, and provide clinical education.
  • Offer immediate clinical consultation to case management nurses for urgent issues.
  • Review cases to determine care levels and coordinate peer reviews as necessary.
  • Document and track cases requiring retrospective external appeals.
  • Assess cases for concurrent quality review and coordinate action plans for identified concerns.
  • Identify opportunities for workflow improvements in case management and discharge planning.
  • Collaborate with the case management leadership team to drive performance enhancements.
  • Generate appeal letters as required.
  • Identify high-utilization patients and coordinate care plans accordingly.
  • Provide advisory support across all WellSpan entities as needed.

Expectations:

  • Thoroughly document review activities in line with established policies.
  • Familiarity with national guidelines such as InterQual and Milliman.
  • Provide daytime coverage for physician advisory services.
  • Adhere to WellSpan Case Management policies and procedures.
  • Maintain confidentiality of patient information in all communications.
  • Exhibit professionalism and a collaborative approach in interactions.
  • Deliver exceptional service to all stakeholders and foster teamwork.
  • Participate in weekend and holiday coverage as required.
  • Prepare and present utilization data analyses as needed.
  • Develop educational initiatives on utilization management principles.
  • Assist with special projects as necessary.
  • Attend required meetings and huddles.

Qualifications:

Education:

  • Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) required.

Experience:

  • Minimum of 5 years in clinical practice within hospital medicine.
  • Preferred experience in peer review or case management, particularly in Family Medicine, Internal Medicine, or General Surgery.

Licenses:

  • Must possess a valid Medical Physician and Surgeon license or Doctor of Osteopathic Medicine license upon hire.

Skills and Abilities:

  • Comprehensive understanding of EMR systems.

Commitment to Values:

WellSpan Health is dedicated to upholding professionalism, integrity, and ethical standards in all operations. We are an Equal Opportunity Employer, committed to fair treatment for all applicants and employees.


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