Clinical Utilization Advisor

Clinical Utilization Advisor

Job No: 496974
Department: PHYSICIANS - MEDICINE
Local

Title:

Clinical Utilization Advisor
Budget

Title:

Teaching Hospital Associate Administrator
Work Type: Full Time
Location: Brooklyn, NY
Categories: Management and Professional, Administrative, Patient Care

Are you looking to take your career to new heights with a leader in healthcare? SUNY Downstate Health Sciences University is one of the nation's leading metropolitan medical centers. As the only academic medical center in Brooklyn, we serve a large population that is among the most diverse in the world. We are also highly-ranked by Castle Connolly Medical, a healthcare rating company for consumers, among the top 5 leading U.S. medical schools for training doctors.

Bargaining Unit:

UUP

Job Summary:

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…