Clinical Utilization Advisor

Are you looking to take your career to new heights with a leader in healthcare SUNY Downstate Health Sciences University is one of the nations 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 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.

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.

Work Schedule:

Variable Days; Variable Hours (Full-Time)

Salary Grade/Rank:

Salary Range:

Commensurate with experience and qualifications

• $160000 - $180000 Total Annual Salary

Executive Order:

Pursuant to Executive Order 161 no State entity as defined by the Executive Order is permitted to ask or mandate in any form that an applicant for employment provide his or her current compensation or any prior compensation history until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time please contact the Governors Office of Employee Relations ator via email at.

Equal Employment Opportunity Statement:

SUNY Downstate Health Sciences University is an affirmative action equal opportunity employer and does not discriminate on the basis of race color national origin religion creed age disability sex gender identity or expression sexual orientation familial status pregnancy predisposing genetic characteristics military status domestic violence victim status criminal conviction and all other protected classes under federal or state laws.

Women minorities veterans individualswith disabilities and members of underrepresented groups are encouraged to apply.

If you are an individual with a disability and need a reasonable accommodation for any part of the application process or in order to perform the essential functions of a position please contactHuman Resources at