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MEDICAL DIRECTOR - UTILIZATION MANAGEMENT

Company: Huntington Hospital
Location: Pasadena
Posted on: January 15, 2020

Job Description:

When you join Huntington Hospital in Pasadena, CA, you are aligning yourself with an organization whose values drive our philosophy of care. Our focus on delivering quality, service, and cutting edge care, enables Huntington Hospital to be an organization committed to patient outcomes-not the bottom line. More importantly, it empowers you to enact change and deliver the results that continuously improve our ability to provide our community with care.

Huntington Hospital has a utilization management program to ensure the appropriate utilization of all inpatient services provided to Hospital patients.

The UM Medical Director oversees and performs administrative services necessary to operate and carry out the Utilization Management Plan for inpatient services.

Responsibilities:-- Oversee Hospital's Utilization Management Plan.--

Chair and participate in the Utilization Management Committee meetings monthly.

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Be available on site at hospital Monday-Friday, 8 hours per day or as otherwise mutually agreed to with the hospital.

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Serve as Consultant to Case Management, Revenue Integrity and Health Information Management (HIM) departments, as requested.

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Participate in and/or review utilization management functions, payor determinations and appeals, as requested.

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Conduct second level medical necessity reviews for all patient cases that do not meet first level screening criteria or do not have a documented expectation of length of stay.

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Provide recommendations on inpatient admissions, outpatient and observation services, and other hospital level services.

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Review and/or sign Condition Code 44 cases.

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Perform commercial payer reviews and denial appeals, as needed and appropriate.

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Conduct peer to peer discussions with commercial payer medical directors for cases that are being concurrently denied.

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Review length of stay and facilitate discussions with the Attending physician about the plan of care.

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Communicate questions, concerns and findings to physicians as needed, to ensure and facilitate compliance with the Hospital's Utilization Management Plan and hospital policies.

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Offer guidelines about level of care, length of stay, readmissions and other utilization issues.

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Follow the Utilization Management Plan's process for physician disagreements.

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Conduct a concurrent review of government and/or commercial cases to evaluate the opportunity for additional specificity for documentation based upon available information.

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Educate hospital staff and physicians on utilization management and documentation quality issues, as requested, including medical necessity criteria and regulations.

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Attend Denials Management Committee, Quality Management Committee, Medicine Committee, Surgery Committee, PT&D and other medical staff committees and sections as requested.

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Attend Rounds with Case Management, academic Hospitalists and internal medicine Residents, as needed and requested.

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Must meet minimum patient activity thresholds to maintain active medical staff privileges at Huntington Hospital.

This position is full-time, with availability by phone and remote access to the EHR. On-site attendance at meetings and case conferences is expected during business hours.

Qualifications:

Education/Licensure

MD or DO, board certified, preferably in primary care specialty (internal medicine, family medicine, Emergency Medicine). Must have current unrestricted CA Medical License and CA DEA certificate.

Experience/Training:

Minimum 5 years experience in utilization management. Prior experience as Medical Director preferred. CCDS or other clinical documentation training preferred.

Keywords: Huntington Hospital, Pasadena , MEDICAL DIRECTOR - UTILIZATION MANAGEMENT, Executive , Pasadena, Texas

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