Medical Director of Case Management and Utilization Review

The Medical Director of Case Management and Utilization Review leads the hospital specific execution of the Case Management (CM) and Utilization Management (UR) and related activities. The Medical Director functions as the primary physician advisor for the hospital and supervises other Physician Advisors for that hospital. As an active member of the UR Committee and in collaboration with it, identifies opportunities to improve utilization of hospital resources and the quality of patient care. Assists the Case Management staff in resolving patient care issues for referred cases, provides physician education, and assists the hospital and medical staff in developing and promoting resource management goals and objectives. This position reports to the Senior Medical Director of Case Management and Utilization Management. Responsibilities Education and Clinical Documentation Improvement: Supports education and clinical documentation improvement. This includes, but not limited to: At least annually, educates and communicates to the medical staff the role and benefits of case management. Assists in conducting medical necessity education in collaboration with the Senior Medical Director and Physician Advisors. Provides ad hoc education and discussion regarding resource management cases with physicians. Assists physicians in improving the quality of documentation and serves as a liaison between Health Information Management (HIM) Department and the medical staff. Complex Care Management: Leads Complex Care Management. This includes, but not limited to: Leads hospital initiatives to reduce complex patient length of stay, in conjunction with nursing director of case management. Leads hospital complex care meeting in collaboration with case management leadership. Responds proactively to escalation of care delays, particularly related to clinical care, physician decision making, and patient and family related discharge barriers. Works with physicians on efficient care of observation patients and serves as liaison to insurance companies for prior authorizations creating discharge delay. Case Management and Utilization Review: Supports the overall enterprise of the Case Management and Utilization Review. This includes, but not limited to: Makes decisions on referred individual patient cases regarding pre-admission authorization, medical necessity and services/setting, appropriateness of admission and continuation stay. Provides peer review services for medical necessity of admission or continued stay, conformance to professional standards for quality patient care, and for other cases referred by CE staff. Supports the Senior Medical Director in Medical Staff Education. Assists physicians in improving the quality of their medical necessity documentation and works with MDs on efficient care of observation patients. Serves as liaison to insurance companies for prior authorizations and removes barriers to discharge. Supports case management by attending interdisciplinary rounds (IDR) and provides feedback and suggestions to physicians and CMs. Serves as liaison to case management, social workers, nursing staff, individual physicians, and the medical staff. Communicates with Centralized UR staff and serves as support and back-up for case management escalations during and outside of IDRs. Annual Initiatives: Develops UM/resource management studies and projects including fiscal data to improve utilization and patient flow in collaboration with the URC and CM leadership. May include single DRG studies and different physician practice patterns and utilization; works with physicians to change practices and improve outcomes. Utilization Review Committees: Co-leads hospital specific UR Committee and is a member of the system UR Committee. Makes decisions on referred individual patient cases regarding pre-admission authorization, medical necessity and services/setting, appropriateness of admission and continuation of stay. Competencies Education and Certification Requirements: Medical Doctor (Required)Medical Doctor License (ME LICENSE) - State of Florida (FL), Osteopathic Physician License (OS LICENSE) - State of Florida (FL) Additional Job Information Complexity of Work: Essential Competencies and Skills: Excellent customer service and interpersonal skills. Able to effectively present information, both formal and informal. Strong written and verbal communications skills with all levels of internal and external customers. Strong analytical skills. Strong organizational skills and the ability to set priorities and multi-task. Demonstrated flexibility, teamwork, and accommodation to change in the healthcare environment. Ability to drive results and produce outcomes. Required Work Experience: Extensive experience in one or more branches of medicine or surgery; at least, five (5) post-training years of medical staff organization/administrative experience in a large acute care hospital. Other Information: Additional Education Info: Graduate of a medical school approved by the Council on Medical Education of the American Medical Association. #J-18808-Ljbffr