Medical Director of Case Management and Utilization Review MHM

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Join to apply for the Medical Director of Case Management and Utilization Review - FT Days - MHM role at Memorial Healthcare System

Location:

Miramar, Florida

At Memorial, we are dedicated to improving the health, well-being and, most of all, quality of life for the people entrusted to our care. An unwavering commitment to our service vision is what makes the difference. It is the foundation of The Memorial Experience.

Summary

The Medical Director of Case Management and Utilization Review leads the hospital specific execution of the Case Management (CM) and Utilization Management (UR) and related activities. The Medical Director functions as the primary physician advisor for the hospital and supervises other Physician Advisors for that hospital. As an active member of the UR Committee and in collaboration with it, identifies opportunities to improve utilization of hospital resources and the quality of patient care.

Assists the Case Management staff in resolving patient care issues for referred cases, provides physician education, and assists the hospital and medical staff in developing and promoting resource management goals and objectives. This position reports to the Senior Medical Director of Case Management and Utilization Management.

Responsibilities

Utilization Review Committees:

Co-leads hospital specific UR Committee and is a member of the system UR Committee. Makes decisions on referred individual patient cases regarding pre-admission authorization, medical necessity and services/setting, appropriateness of admission, and continuation of stay.

Annual Initiatives:

Develops UM/resource management studies and projects including fiscal data to improve utilization and patient flow in collaboration with the URC and CM leadership. May include single DRG studies and different physician practice patterns and utilization; works with physicians to change practices and improve outcomes.

Case Management and Utilization Review:

Supports the overall enterprise of the Case Management and Utilization Review. This includes, but not limited to:

Makes decisions on referred individual patient cases regarding pre-admission authorization, medical necessity and services/setting, appropriateness of admission, and continuation stay. Provides peer review services for medical necessity of admission or continued stay, conformance to professional standards for quality patient care, and for other cases referred by CE staff. Supports the Senior Medical Director in Medical Staff Education. Assists physicians in improving the quality of their medical necessity documentation and works with MDs on efficient care of observation patients.

Serves as liaison to insurance companies for prior authorizations and removes barriers to discharge. Supports case management by attending interdisciplinary rounds (IDR) and provides feedback and suggestions to physicians and CMs. Serves as liaison to case management, social workers, nursing staff, individual physicians, and the medical staff. Communicates with Centralized UR staff and serves as support and back-up for case management escalations during and outside of IDRs.Complex

Care Management:

Leads Complex Care Management. This includes, but not limited to:
Leads hospital initiatives to reduce complex patient length of stay, in conjunction with nursing director of case management. Leads hospital complex care meeting in collaboration with case management leadership. Responds proactively to escalation of care delays, particularly related to clinical care, physician decision making, and patient and family related discharge barriers. Works with physicians on efficient care of observation patients and serves as liaison to insurance companies for prior authorizations creating discharge delay.

Education and Clinical Documentation Improvement:

S…