Utilization Management Physician Advisor - Medical Director - UnityPoint Health

The Utilization Management Physician Advisor Medical Director is responsible for teaching, consulting, and advising the Utilization Management department, the medical staff and the hospital leadership.  The UM Physician Advisor Medical Director is charged with meeting UnityPoint Health’s goals and objectives for assuring the effective, efficient utilization of health care services. The UM Physician Advisor Medical Director is expected to have expertise on matters regarding physician practice patterns, over and under-utilization of resources, medical necessity, levels of care, care progression, denial management, compliance with governmental and private payer regulations, appropriate physician coding and documentation requirements.  The UM Physician Advisor Medical Director demonstrates accountability, which is exhibited in a variety of ways: supports performance improvement to drive utilization management metrics, remains current on healthcare and payor regulatory provisions, provides timely follow up on case prioritization with physicians and Utilization Management leaders, and attends utilization review meetings. The position reviews cases as needed to meet criteria for medical necessity, quality, and desired outcomes. The UM Physician Advisor Medical Director is involved in the denial management process and conducts peer to peers on denied accounts along with providing recommendations on formal appeals.  The position is responsible for addressing and escalating challenging, high conflict or outlier case circumstances, and serves as a mentor for clinical documentation.  The UM Physician Advisor Medical Director will establish strong relationships across the organization, working closely with Utilization Management, Payor Innovations Care Management, Revenue Cycle, Finance, CDI, and the Medical Staff.

The UM Physician Advisor Medical Director aligns and drives performance improvement opportunities within the Medical Staff and Utilization Management to achieve the highest quality and regulatory compliance. A keen understanding of the payor market and managed care contracts is essential.  Essential to the UM Physician Advisor Medical Director role is the ability to identify, interpret, synthesize, and apply relevant quality measures to achieve meaningful outcomes. The UM Physician Advisor Medical Director leverages outcome data to drive and improve strategic organizational performance and demonstrates expertise in optimizing the electronic medical record.

Acute Inpatient, Utilization Management, and Clinical Documentation Improvement Functions (60% of time)

• Maintains knowledge of regulatory and accreditation requirements related to utilization review (UR), Medicare COP, LOC and clinical documentation.
• Works with Compliance to interpret new regulatory and compliance requirements and works with the System Medical Director of Utilization Management to develops standard system-wide implementation plans and policies.
• Partners with the System Medical Director of Utilization Management to set the strategic direction of the internal Utilization Management physician advisor program within the health system.
• Maintains current knowledge of federal, state, and payer regulatory and contract requirements. Educates and updates the medical staff on respective requirements.
• Maintains accountability for achieving utilization management outcomes and fulfills the obligations and responsibilities of the role to support the medical staff in the clinical progression of patient care.
• Upholds the organization’s values of teamwork and professionalism and applies Code of Conduct standards to all members of the healthcare team.
• Provide strategies to minimize risk and reduce provider liability or loss of inpatient revenue.
• Assist with length of stay management and utilization of resources while collaborating with utilization management and care management teams.
• Provides consultation to Utilization Management staff regarding complex clinical issues and advises on justification required for continued stay, medical necessity and utilization management.
• Reviews medical records of patients identified by Utilization 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.
• Identifies trends by payer and assists with the denial management process both pre and post bill and escalates to the System Medical Director of Utilization Management.
• Works with Payor Innovations Care Management in Payor contracting if requested.
• Act as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate by adequately preparing for, and participating in, Peer-to-Peer discussions.
• Provide regular feedback to physicians and all other stake holders regarding level of care, length of stay, and potential quality issues.
• Facilitate pre-payment reviews and/or participating in recovery audit contractor reviews as requested.
• Assist Hospital Administration and the Medical Staff related to any regulatory audits, investigations, surveys, or other review of the Departments.
• Participates in review of long stay patients, in conjunction with the Utilization Management Leadership, Utilization Management team, and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care.
• Participates in organizational efforts to reduce inappropriate readmissions when requested.
• Responds to requests for assistance on clinical reviews for medical necessity or any other reason, by any member of the Utilization Management department in a timely fashion.

Physician Support and Education (30% of time)

• Work with regional UM staff and the System Medical Director of Utilization Management to outline educational opportunities for providers and other clinicians related to regulatory requirements, appropriate utilization of hospital services, community resources, and alternative level of care.
• Work with regional UM staff and the System Medical Director of Utilization Management to outline and provide educational opportunities for providers regarding appropriate clinical documentation improvement and care standards when requested.
• Investigates trends on avoidable day and discharge delay concerns referred by utilization management staff that effect patients' outcomes during their hospital stay.
• Works collaboratively with utilization management, care management, and managed care innovation teams to act a liaison with medical directors at contracted payers as needed.
• Identifies denial trends and works with the System Medical Director of Utilization Management, the medical staff and hospital administration to resolve issues.
• Works collaboratively with the System Medical Director of Utilization Management, Physician Advisor colleagues (internal and external) and UM Staff to provide consistent, high quality secondary reviews and discuss difficult cases and industry/regulatory changes by participating in Physician Advisor Quality meetings.

Basic UPH Performance Criteria (10% of time)         

• Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.
• Demonstrates ability to meet business needs of department with regular, reliable attendance.
• Employee maintains current licenses and/or certifications required for the position.
• Practices and reflects knowledge of CMS COP, HIPAA, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.
• Completes all annual education and competency requirements within required timeframes.
• Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of the System Medical Director of Utilization and/or Hospital Senior Leadership. Takes appropriate action on concerns reported by department staff related to compliance.

• Hold an unrestricted license to practice medicine or license eligible in Iowa, Illinois, or Wisconsin. License requirement is based on market supporting.
• Able to effectively present information, both formal and informal
• Historical or current board certification in relevant clinical field
• Unrestricted license to practice medicine or license eligible in Iowa, Illinois, or Wisconsin. License requirement is based on market supporting.
• Strong analytical skills
• Strong written and verbal communications skills with all levels of internal and external customers
• Strong organizational skills and ability to set priorities and multi-task, demonstrates flexibility, teamwork, and is accustomed to change in the healthcare environment.
• Demonstrates ability to drive results and produce outcomes.
• Exceptional interpersonal and communication skills
• Knowledge and experience with Medicare, Medicaid and Commercial payor hospital surveys
• Customer/patient focused
• Critical thinking skills using independent judgment in making decisions
• Strong clinical acumen
• Working knowledge of third-party payor guidelines/medical necessity criteria such as InterQual® (e.g., knowledge of admission criteria for all levels of care)
• Experience with denials management
• Knowledge of process improvement methodology
• Action Planning
• Ability to work independently
• Highly motivated, self-starter who works effectively with minimum supervision
• Ability to organize work quickly and efficiently and be comfortable working against deadlines
• Maintain effective working relationships
• Excellent collaboration and team building skills

Preferred:

• Five years recent clinical experience in in a hospital setting
• Previous experience as a physician advisor or equivalent experience with Utilization Management
• Certification by American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or The American College of Physician Advisors