Utilization Specialist

WHO WE ARE

NeueHealth is a value-driven healthcare company grounded in the belief that all health consumers are entitled to high-quality, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to make healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.

NeueHealth delivers clinical care to health consumers through our owned clinics – Centrum Health and Premier Medical – as well as unique partnerships with affiliated providers across the country. We also enable providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-centric approach, we are committed to transforming healthcare and creating a better care experience for all. 

The Clinical Review Analyst supports population health and value-based care initiatives through comprehensive review and analysis of patient medical records, utilization, and healthcare cost information. This role evaluates high-risk, and recently hospitalized patients to identify drivers of hospital admissions, readmissions, and healthcare expenditures, as well as relevant clinical and risk factors.

DUTIES & RESPONSIBILITIES

• Review patient medical records, encounter documentation, hospital records, and other available clinical information to understand patient conditions, treatment history, and healthcare utilization.
• Analyze clinical information to identify key diagnoses, conditions, treatment patterns, and other factors contributing to healthcare utilization.
• Review additional clinical, utilization, and financial data as necessary to develop a comprehensive understanding of patient healthcare needs and utilization.
• Synthesize complex medical information into clear, concise summaries for use by clinical and operational teams.
• Maintain accurate and complete documentation of review findings in designated systems and tracking tools.
• Review medical records for patients recently discharged from an inpatient setting to understand the reason for admission, hospital course, discharge disposition, and relevant clinical factors.
• Identify factors potentially contributing to hospitalization, readmission risk, or ongoing healthcare utilization.
• Summarize hospitalization findings, relevant diagnoses, and other pertinent information in established tracking tools.
• Support multidisciplinary review of high-risk and recently hospitalized patients by providing accurate and timely clinical information.
• Participate in patient review meetings and provide relevant findings as requested.
• Perform medical record reviews for patients identified as high-risk or high-utilizing.
• Review available medical, pharmacy, claims, and financial information to identify factors contributing to healthcare expenditures.
• Evaluate utilization associated with Medicare Part A, Part B, and Part D services, as applicable, and summarize significant drivers of cost.
• Identify patterns of utilization and relevant clinical conditions that may contribute to elevated healthcare expenditures.
• Document findings in designated tracking tools and provide information needed to support clinical and operational review.
• Review clinical documentation for conditions that may represent potential HCC or other risk-adjustment opportunities.
• Identify potentially relevant diagnoses or clinical conditions for further evaluation by appropriate coding, risk adjustment, or clinical personnel.
• Escalate documentation or diagnosis questions to designated stakeholders when additional review is necessary.
• Support organizational risk-identification activities while maintaining appropriate separation between clinical review and formal coding validation responsibilities.
• Collaborate with clinical, population health, care management, risk adjustment, and operational teams to communicate review findings.
• Participate in meetings related to high-risk, high-risk, readmission, or patient utilization reviews.
• Maintain tracking spreadsheets, reports, and other documentation used to monitor patient review findings and trends.
• Assist with special analyses, projects, and reporting related to patient utilization, clinical risk, healthcare costs, and population health initiatives.
• Protect patient confidentiality and comply with HIPAA, organizational privacy, security, and confidentiality requirements.
• Perform other related duties and responsibilities as assigned.

EDUCATION AND PROFESSIONAL EXPERIENCE 

• Associate's or bachelor's degree in healthcare, health information management, nursing, public health, healthcare administration, or a related field preferred.
• Relevant clinical, healthcare operations, or medical record review experience may be considered in lieu of degree requirements, depending on organizational requirements.
• Experience reviewing medical records or clinical documentation in a healthcare setting.
• Experience working with electronic health records, preferably eClinicalWorks (eCW).
• Experience in population health, value-based care, utilization management, care management, risk adjustment, Medicare, or healthcare analytics preferred.
• Experience reviewing healthcare claims, utilization, or cost information preferred.
• Familiarity with HCCs and risk-adjustment concepts preferred.

PROFESSIONAL COMPETENCIES

• Ability to read, understand, and interpret medical records and common medical terminology.
• Understanding of healthcare utilization, including inpatient, outpatient, physician, and pharmacy services.
• General knowledge of Medicare Part A, Part B, and Part D services preferred.
• Working knowledge of HCC and risk-adjustment concepts preferred.
• Ability to analyze clinical and financial information and accurately summarize significant findings.
• Strong attention to detail and ability to identify relevant information within complex medical records.
• Strong organizational, time-management, and workload-prioritization skills.
• Ability to manage multiple patient reviews and meet established deadlines.
• Effective written and verbal communication skills.
• Ability to work collaboratively with clinical, operational, and cross-functional teams.
• Proficiency with Microsoft Excel, Word, Outlook, and Teams.
• Experience with eClinicalWorks or a comparable electronic health record system preferred.
• Knowledge of HIPAA requirements and patient confidentiality standards.