Medical Director Revenue Integrity; Lead Physician Advisor

Responsibilities

• Provides functional leadership for the revenue integrity team, including CDI, Coding, and Utilization Review (UR).
• Oversees optimization of revenue integrity systems and operations.
• Chairs the Utilization Management (UM) Committee.
• Supports development, adoption, and utilization of value-based care initiatives.
• Reviews patient medical records identified by case managers or as requested by the healthcare team to perform quality and utilization oversight.
• Performs medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews.
• Provides regular feedback to physicians and other stakeholders regarding level of care, length of stay, and potential quality issues.
• Conducts Peer to Peer discussion with Payor Medical Directors when requested.
• Provides necessary clinical education to UR Case Managers regarding clinical criteria and appropriate use of screening tools.
• Educates individual hospital staff physicians about current ICD and DRG coding guidelines.
• Collaborates with CDI and coding team to develop compliant query practices, optimize review process and provide necessary clinical support in DRG assignment as needed.
• Provides direct clinical support to CDI manager and RAC auditor for DRG level of care denials.
• Conducts physician education sessions to share data, trends, practice patterns, and other relevant information. Documents session outcomes and relevant information.
• Reports practice pattern trends and opportunities to service line or department specific meetings at the request of the CMO or hospital leadership.
• Supports payor contract process and physician contract process for quality measures.
• Participates in efforts to reduce inappropriate readmissions.
• Collaborates with Healthcare Data team to identify areas or processes contributing to excessive cost of care.
• Optimize service line revenues through proactive approaches and strategies.
• Participates in hospital committees to support and develop protocols related to evidence-based medicine and support optimal standards of care.
• Collaborates with the Chief Financial Officer to identify short term and long-term goals.

• Ability to drive strategic direction
• Knowledge of revenue cycle, clinical documentation, and payor relationships
• Ability to educate providers and stakeholders in a timely and effective manner
• Process improvement, quality improvement, planning, and decision-making skills
• Knowledge of regulatory requirements
• Advanced knowledge of patient safety principles, risk management, and strategies to minimize harm
• Ability to build rapport with stakeholders to obtain buy-in and collaboration towards goals
• Strong knowledge of Medicare Two Midnight rules
• Ability to interact respectfully with diverse cultural and socio-economic populations

• Hold and maintain or able to obtain an unrestricted medical license in the state of Wyoming.
• Ten (10) or more years of healthcare and/or patient care experience
• Two (2) or more years of healthcare business, revenue cycle, utilization management, coding, clinical documentation improvement principals, or government/regulatory value programs related experience
• Current American College of Physician Advisors (ACPA) membership
• 6 months (one of the following must be obtained within six (6) months of start date):
• Current American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) certificate within six (6) months of start date
• Current American College of Physician Advisors Certification (ACPA-C) from the American College of Physician Advisors (ACPA) within six (6) months of start date

• Certified Medical Director (CMD)
• Medical billing, coding, or abstracting experience
• Internal Medicine experience with a background in Hospital Medicine
• Inter Qual experience
• MCG experience