Utilization Review & Clinical Documentation Specialist

Position Summary

The Utilization Review & Clinical Documentation Specialist is responsible for continuously reviewing hospital patients, with a primary focus on patients placed in Observation status, to determine whether the patient's clinical condition, treatment intensity, and supporting documentation meet criteria for Inpatient admission.

This role requires a robust medical and clinical background. The specialist must be able to independently review the entire clinical picture, including physician notes, nursing documentation, laboratory results, imaging, vital signs, medications, treatment plans, and changes in the patient's condition.

A major function of this position is identifying situations where a patient may clinically support Inpatient admission, but the medical record does not adequately capture the patient's severity of illness, clinical risk, intensity of services, or other information necessary to support the appropriate level of care.





The specialist will use MCG criteria and clinical judgment to identify documentation opportunities and work with physicians and clinical teams to ensure the medical record accurately reflects the patient's condition and services being provided.

Key Responsibilities

Observation-to-Inpatient Utilization Review
- Perform ongoing and concurrent review of patients currently in Observation status.
- Determine whether the patient's current clinical condition and treatment meet MCG criteria for Inpatient admission.
- Identify patients whose condition has progressed or whose treatment intensity now supports conversion from Observation to Inpatient.
- Prioritize patients with prolonged Observation stays or significant changes in clinical condition.
- Review newly admitted and existing Observation cases throughout the day rather than relying solely on an initial admission review.
- Escalate cases that appear to support Inpatient status to the attending physician, case m

📌 Utilization Review (Bengaluru)
🏢 OptiClaim
📍 Bengaluru