Medical Director Care Coordination Physician Advisor Utilization

2 weeks ago


McHenry Illinois, United States Northwestern Memorial Healthcare Full time
Job Description

The Medical Director, Care Coordination reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

Responsibilities:

Partners with leadership and the Case Management/UR team on improvement in the overall quality, completeness and accuracy of medical documentation for NM patients. 

Reviews recognized outside expert opinions and partners with medical staff experts and utilization review leadership and team to develop parameters for appropriate hospital status and billing.

Educates all members of the patient care team, through day-to-day interactions and intermittent group presentations on utilization review guidelines on an on-going basis.

Performs Medical Record retrospective and concurrent reviews and other data collection activities that assist in identifying potential quality issues and opportunities for improvement in documentation of patient care and services. 

Completes formal Utilization Review Training at regular intervals as determined by Program Leadership.

Promote the efficient and effective clinical care of hospitalized patients via collaborative telephonic communication and interactions with hospital clients.

Facilitate communication between managed care/commercial payers and providers regarding benefit coverage issues, utilization review and quality assurance processes.

Promote payer and provider adherence to Joint Commission standards, state regulations, and all other applicable regulatory standards.

Promote hospital adherence to ensure compliance with CMS policy regarding inpatient admissions and observation status, as well as the appropriateness of continued hospital stay.

Provide in-depth clinical expertise in the management of specific patient populations to effectively manage length of stay for hospital clients and facilitate care across the healthcare continuum by intervening as necessary to address barriers to timely and efficient care delivery and reimbursement.

Discuss and educate treating physicians regarding alternative courses of action or modification to the treatment plan, including but not limited to, appropriate documentation of the plan of care, to resolve utilization issues and/or ensure professionally recognized standards of quality are being met.

Document clearly and concisely all interactions, interventions and outcomes of physician advisory work performed for clinical issues and time keeping system for billing issues.

Serves on the hospital Utilization Review (UR) Committee.

Conducts case reviews that are deemed not medically necessary for admissions or continued stay in conjunction with the treating physician and/or another member of the UR committee. Communicate the decision to the case management staff to issue written notification (HINN/ABN/commercial letter of non-coverage) to the patient and the treating physician.

Conduct verbal and written review and appeal of denied coverage determinations made by commercial/managed care payers, MAC, ADR or CERT audits when requested.

Assists in proactively reviewing assigned avoidable days and addresses these issues with individual physicians and/or practice leaders.

Responsible for attending requested and required hospital meetings, including regularly scheduled meetings with other administrative leaders in their area.

Collaborates and communicates effectively with other administrative leaders, as well as all team members to assure consistency across the department.

The physician is expected to report the number of hours spent performing these activities on a monthly basis in an NM approved format.

Performs other related duties as required.

#INDC



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