Medical Director Care Coordination Physician Advisor Utilization

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.

Qualifications

Required:

• Current Illinois medical license in good standing
• Shall be and remain a member in good standing of the NM Medical Staff
• Shall be qualified by training, experience, interest, demonstrated current ability, and board certification in the clinical area covered by the department.
• Must be knowledgeable about working with an adult population ranging from adolescent to geriatric, including patients with communications barriers, sensory impairment, and physical limitations, including but not limited to developmental, mobility, vision or hearing impairments
• Must be able to identify appropriate measures and accommodations to meet the needs of the department
• Must be able to communicate and interact effectively with payers to resolve issues.
• Three or more years of clinical medical practice
• Knowledge of the NM electronic medical record system

Preferred:

• Should possess strong interpersonal skills, excellent clinical judgment and quality assessment skills

Equal Opportunity

Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.