Job Description
The Department of Medicine at SUNY Downstate Health Sciences University is seeking a full-time TH Associate Administrator / Clinical Utilization Advisor.
The Clinical Utilization Advisor plays a critical role in optimizing healthcare delivery by providing guidance on medical necessity, utilization management, and quality improvement initiatives. They collaborate with healthcare teams to ensure compliance with regulatory standards and promote cost-effective care delivery. This is a full-time position that will work closely with the Physician Advisor, and reports to the Chief Medical Officer or designee.
Key Functional Duties
- Utilization Review Support: Review medical records and clinical documentation to support utilization management processes, identifying opportunities for alignment with regulatory requirements, payer guidelines, and organizational standards. Escalate clinical questions to licensed clinicians as appropriate, and participate in organizing the Utilization Review Committee
- Medical Necessity Analysis (Advisory): Provide advisory analysis of medical necessity for procedures, treatments, admissions, and level-of-care determinations (e.g., inpatient vs. observation) using established criteria and guidelines. Support licensed clinicians by preparing case summaries and recommendations; final determinations rest with credentialed providers.
- Denial Prevention, Management & Appeals Support: Support the denial management and appeal process by providing clinical analysis and documentation review to strengthen appeal submissions. Identify denial trends, perform root cause analysis, and implement targeted prevention strategies, including physician education on documentation best practices and alignment with ICD-10 coding and medical necessity criteria. Collaborate with ED to address front-end drivers of denial risk by reducing avoidable admission and observation cases and improving level-of-care documentation at the point of entry.
- Discharge Planning Optimization: Collaborate with case management, social work, nursing, and physician leadership to optimize discharge planning and interdisciplinary rounds (IDR), supporting appropriate length of stay and efficient transitions of care while maintaining patient safety and quality.
- Education & Training: Develop and deliver education to physicians and clinical teams on utilization management principles, documentation improvement, regulatory expectations, and payer requirements, in collaboration with Compliance, CDI, and Revenue Cycle leadership.
- Clinical Documentation Improvement (CDI) Collaboration: Partner with the CDI team to promote accurate, complete physician documentation with the goal of improving utilization appropriateness, case mix index (CMI), and risk-adjusted quality and safety measures.
- Interdisciplinary Collaboration: Work closely with physicians, nurses, case managers, administrators, and other stakeholders to foster effective communication, alignment, and consistency across utilization management and care coordination workflows.
- Policy & Process Development: Contribute to the development, review, and refinement of utilization management policies, protocols, and workflows, ensuring alignment with regulatory standards and organizational goals.
- Strategic Planning: Will provide direct support to policy making officials and contribute as needed. This role will also include high level policy formulation aimed at streamlining hospital strategy with a specific focus on financial savings.
- High-Cost/High-Risk Procedure Analysis and Review: Analyze utilization patterns for high-risk and high-cost procedures and diagnostic tests. Identify trends, provide advisory recommendations for optimization, and collaborate with clinical leadership to support appropriate use and cost-effective care delivery.
Qualifications
Required Qualifications
- Medical Degree (MD or DO).
- 3 to 5 years of utilization management experience.
- Knowledge of utilization management principles, regulatory requirements, and healthcare economics.
- Strong analytical skills and attention to detail.
- Excellent communication and interpersonal skills.
- Ability to work independently and collaboratively in a fast-paced environment.
- Or a satisfactory equivalent or education, training, and experience.
Preferred Qualifications
- Experience with electronic health records (EHR) and healthcare information systems is preferred.
- Clinical experience in a hospital or healthcare setting is preferred.
