Clinician will focus on utilization review, medical necessity determinations, denial management, and quality improvement across inpatient, observation, and discharge planning workflows. The role partners closely with case management, CDI, physicians, nurses, and administrators to support appropriate documentation, regulatory compliance, and cost-effective care. Up to 25% of the position includes clinical duties, with leadership of utilization management processes and committee work.
Key Responsibilities
- Review medical records and documentation to assess appropriateness of services and compliance with utilization guidelines.
- Determine medical necessity for procedures, treatments, hospital admissions, and level-of-care decisions.
- Coordinate with case managers, social workers, and providers to support discharge planning and optimize length of stay.
- Lead denial appeals, review denial trends, and perform root cause analysis to reduce future denials.
- Provide education on utilization management, documentation best practices, ICD-10 alignment, and regulatory compliance.
- Collaborate with CDI to improve physician documentation, utilization, case mix index, and risk-adjusted quality measures.
- Participate in policy, protocol, and procedure development for utilization management.
- Monitor utilization, quality, and financial performance metrics and help lead the utilization management committee.
Required
- MD or DO degree.
- Active medical license.
- Knowledge of utilization management principles, regulatory requirements, and healthcare economics.
- Strong analytical, communication, and interpersonal skills.
- Ability to work independently and collaboratively in a fast-paced environment.
Preferred
- Experience with electronic health records and healthcare information systems.
- Clinical experience in a hospital or healthcare setting.
Benefits & Perks
- Full-time role with part-time availability to inquire about.
- Total compensation range of $275,000 to $325,000.
- Leadership responsibility over utilization management committee work and process improvement.