MEDICAL DIRECTOR - UTILIZATION MANAGEMENT
Company: Huntington Hospital
Posted on: January 15, 2020
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
Huntington Hospital has a utilization management program to ensure
the appropriate utilization of all inpatient services provided to
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
Chair and participate in the Utilization Management Committee
Be available on site at hospital Monday-Friday, 8 hours per day or
as otherwise mutually agreed to with the hospital.
Serve as Consultant to Case Management, Revenue Integrity and
Health Information Management (HIM) departments, as requested.
Participate in and/or review utilization management functions,
payor determinations and appeals, as requested.
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.
Provide recommendations on inpatient admissions, outpatient and
observation services, and other hospital level services.
Review and/or sign Condition Code 44 cases.
Perform commercial payer reviews and denial appeals, as needed and
Conduct peer to peer discussions with commercial payer medical
directors for cases that are being concurrently denied.
Review length of stay and facilitate discussions with the Attending
physician about the plan of care.
Communicate questions, concerns and findings to physicians as
needed, to ensure and facilitate compliance with the Hospital's
Utilization Management Plan and hospital policies.
Offer guidelines about level of care, length of stay, readmissions
and other utilization issues.
Follow the Utilization Management Plan's process for physician
Conduct a concurrent review of government and/or commercial cases
to evaluate the opportunity for additional specificity for
documentation based upon available information.
Educate hospital staff and physicians on utilization management and
documentation quality issues, as requested, including medical
necessity criteria and regulations.
Attend Denials Management Committee, Quality Management Committee,
Medicine Committee, Surgery Committee, PT&D and other medical
staff committees and sections as requested.
Attend Rounds with Case Management, academic Hospitalists and
internal medicine Residents, as needed and requested.
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.
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.
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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