Medical Director, Care Management System Level Position Advocate Health Midwest – Illinois

Major Responsibilities:

• Utilization Management:
  • Provides second level review for level of care determination for cases referred by UM staff.
  • Review cases, as appropriate, to identify potential for delay in care delivery that can impact transition to next lower level of care or extend LOS. Discuss case with UM/CM staff, site physician advisor, and/or attending physician, as needed
  • Daily review of cases referred by UM staff and provides guidance, documents outcomes, and follows up as needed with staff. Discuss cases with site physician advisor and/or attending physician, as needed
  • Works with contracting providing recommendations regarding review process and policies with payers
  • Reviews cases as part of the Medicare Inpatient short stay review process to evaluate compliance with the CMS “Two Midnight Rule”
  • Reviews cases where a peer to peer has been offered by a payer and completes the peer-to-peer discussion if needed

•  Denials / Appeals:
  • Acts as a liaison with payers to facilitate approvals and prevent denials
  • Assists with the denial management process and related process. improvement opportunities for the system and sites
  • Works with denial specialists on developing a response to payer denials
  • Participates in discussions with payers to assist in reversing denials including Peer to Peer discussions

• Provides education to physicians, other clinicians, and UM/CM/Denials/ Revenue recovery staff related to regulatory requirements, appropriate utilization, and payer behaviors.

• Serves as consultant and resource to Site Medical Directors of Care Management / Physician Advisors and attending physicians regarding their decisions relative to appropriateness of hospitalization, level of care selection, and continued stay cases.

• Facilitates internal and external relationships with all physicians and constituents of CM/UM and revenue cycle.

• Conducts education sessions utilizing reports with clinical and financial information to mentor the site physician advisors on site KRA goals and process measures and with revenue cycle staff as appropriate.

• Demonstrates knowledge of nationally recognized medical necessity criteria and ICD-10 guidelines. Maintains current knowledge of federal, state and payer regulatory and contract requirements. Attends continuing education sessions pertaining to utilization and quality management.

• Establishes a culture of collaboration and integration that enhances the provision of excellent, safe, and reliable patient care.
• Assists the medical director and leaders of CM, UM, revenue integrity and denials in establishing a culture of open communication, accountability and timely decision making within the division.

Licensure, Registration, and/or Certification Required:

• Medicine and Surgery, MD-DO license issued by the state in which the team member practices, and
• Physician board certification issued by an appropriate board recognized by the American Board of Medical Specialties or the American Osteopathic Association.
• Eligibility for active membership on the hospital’s medical staff
• Current physician advisor certification thru ABQUARP (Certification in Health Care Quality and Management), American College of Physician Advisors (ACAP-C) or Association of Physician Leadership in Care Management (Care Management Physician Certification).  If not certified on hire date, certification will be required within 2 years of hire date.

Education Required:

• Doctorate Degree in Medicine or Doctor of Osteopathic Medicine

Experience Required:

• Typically requires 5 years of experience in utilization management and/or clinical practice.
• Salary Range is typically between $280,000 and $312,000 annually .

Knowledge, Skills & Abilities Required:

• Skills in diplomacy and negotiation in peer interactions regarding utilization issues.
• Demonstrates knowledge of medical necessity criteria and ICD-10 guidelines.
• Maintains current knowledge of federal, state and payer regulatory and contract requirements.
• Ability to utilize computer based medical record and other electronic tools in conduction reviews, reviewing data, and documenting as appropriate to role.
• Strong analytical and decision-making skills.
• Strong leadership and interpersonal skills. Ability to communicate effectively.

Physical Requirements and Working Conditions:

• This position requires travel, therefore, will be exposed to weather and road conditions. Operates all equipment necessary to perform the job.
• Exposed to a normal office environment.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.