HARISH RATHOD

Key Responsibilities: Utilization Management & Review

• Delivered second-level reviews for admission status certification with expertise in clinical and regulatory compliance.
• Advised on medical necessity, hospital reimbursement, quality assurance, and utilization management.
• Provided education to case management and medical staff on regulatory guidelines.
• Review and validate hospital admissions, ensuring they meet medical necessity criteria.
• Provide second-level clinical reviews for inpatient vs. observation status determination.
• Collaborate with case management, utilization review staff, and healthcare providers to improve patient outcomes and optimize resource utilization.
• Evaluate patient care plans to ensure compliance with national standards and payer guidelines.

Compliance & Regulatory Guidance

• Ensure adherence to Medicare and Medicaid regulations, payer policies, and hospital protocols.
• Provide expert guidance on regulatory requirements related to admission status, length of stay, and medical necessity.
• Identify potential compliance risks and implement corrective action plans.

Clinical Documentation Improvement (CDI)

• Work closely with CDI teams to improve the accuracy and completeness of clinical documentation.
• Ensure documentation supports the appropriate severity of illness and risk of mortality.
• Educate physicians on proper documentation to optimize coding and billing outcomes.

Education & Training

• Offer ongoing education to clinical staff on regulatory updates, documentation best practices, and utilization management.
• Conduct case reviews and provide feedback to physicians on how to align clinical documentation with clinical care.

Data Analysis & Quality Improvement

• Participate in quality improvement initiatives to enhance patient outcomes and reduce costs.
• Analyze hospital performance data to identify trends in utilization, readmission rates, and length of stay.
• Support hospital leadership in meeting performance targets.

Care Coordination

• Assist in discharge planning by reviewing patient records and collaborating with the care team.
• Help reduce readmission rates through improved patient management and follow-up care.

Addiction Medicine Responsibilities (Medication-Assisted Treatment - MAT):

• Assessment:Evaluate patients’ medical history, including substance use history.
  Perform physical exams and assess the severity of substance use.
  
• Treatment:Prescribe and manage medications such as methadone, buprenorphine, and naltrexone.
  Create personalized treatment plans incorporating medications, therapies, and counseling.
  Monitor patients for side effects and adjust treatment plans as needed.
  
• Care Coordination:Collaborate with healthcare professionals, including counselors and therapists.
  Participate in interdisciplinary team meetings.
  Refer patients to other health professionals and community agencies for additional support.
  
• Documentation:Accurately document observations, interventions, and care plans.
  Maintain comprehensive and up-to-date medical records.
  
• Education:Educate patients on the benefits and risks of MAT.
  Provide guidance on addiction, recovery, and harm reduction strategies.
  
• Support:Offer ongoing medical care and support to patients and their families throughout the recovery process.
  

• Provided direct inpatient care for 15-20 adult patients daily
• Coordinated internal medicine subspecialty care and participated in quality improvement initiatives

• Delivered emergency medical care in high-pressure settings, ensuring timely diagnosis and treatment

• Co-investigator for multiple clinical studies on postoperative delirium and comparative safety of Celecoxib
• Led research on LDL cholesterol levels and compliance with ATP III recommendations