Medical Director, Utilization Management and Physician Advisory Services

Job Summary

The Medical Director, Utilization Management and Physician Advisory Services (Medical Director) will ensure effective and efficient delivery of quality medical care throughout Cook County Health (CCH) consistent with federal, state, and regulatory standards for physician utilization review management.

The position will also be responsible for overseeing the clinical documentation improvement efforts. The Medical Director will work with CCH senior leadership to identify opportunities to improve Utilization Management and clinical documentation improvement programs.

The position will provide oversight over documentation requirements to support coding, reimbursement, quality and outcomes measurement and medical necessity for the services provided.

General Administrative Responsibilities

Collective Bargaining

• Review applicable Collective Bargaining Agreements and consult with Labor Relations to generate management proposals
• Participate in collective bargaining negotiations, caucus discussions and working meetings

Discipline

• Document, recommend and effectuate discipline at all levels
• Work closely with labor relations and / or labor counsel to effectuate and enforce applicable Collective Bargaining Agreements
• Initiate, authorize and complete disciplinary action pursuant to CCH system rules, policies, procedures and provision of applicable collective bargaining agreements

Supervision

• Direct and effectuate CCH management policies and practices
• Access and proficiently navigate CCH records system to obtain and review information necessary to execute provisions of applicable collective bargaining agreements

Management

• Contribute to the management of CCH staff and CCH’ systemic development and success
• Discuss and develop CCH system policies and procedures

General Administrative Responsibilities continued

Consistently use independent judgment to identify operational staffing issues and needs and perform the following functions as necessary;

hire, transfer, suspend, layoff, recall, promote, discharge, assign, direct or discipline employees pursuant to applicable Collective Bargaining Agreements

Work with Labor Relations to discern past practice when necessary

Typical Duties

• Oversees and provides guidance to Utilization Management, Physician Advisors, and clinical documentation improvement programs.
• Partners with Revenue Cycle and Health Information Management Leadership to create seamless interface with clinicians. Provides oversight over the Clinical Documentation Improvement Program, ensuring effective and efficient documentation.
• Oversees the Physician Advisor staff in the education of medical staff and house staff on new clinical practice guidelines, protocols, research evidence and regulatory requirements including, but not limited to, ICD-10, meaningful use, Centers for Medicare & Medicaid Services (CMS), Joint Commission and compliance.
• Measures and analyzes outcomes for inpatient and observation days. Monitors physician and group patterns and reports the information to physician and hospital committees.
• Chairs and oversees the Stroger Hospital Utilization Management Committees (UMC) and provides feedback to Ambulatory and Community Health Network and Provident Hospital.
• Attends clinical department meetings sharing information specific to department utilization performance, updating the department on internal or external utilization practices, educating physicians on statistical and other review techniques.
• Leads and oversees Utilization Management and Case Management at Stroger Hospital and Provident Hospital.
• Assists with providing leadership and oversight to staff to improve discharge, utilization, length of stay, readmission rates and transitions.
• Contributes to reviews cases under dispute with third party payers and presents the hospital’s case to third party payor Medical Director or Peer Review Board to overturn denials and receive payment.
• Identifies barriers to timely discharge and assists with developing solutions to remove those barriers in collaboration with care management and community partners.
• Collaborates with Revenue Cycle, hospital senior leadership, care coordination, and quality leadership to assist in addressing quality, compliance and denial issues.
• Partners with CCH Leadership to develop and deploy the strategic plan responsible for evolving the Physician Advisory program needs.
• Collaborates with Leadership to develop a process for providing ongoing provider performance feedback in the areas of quality, outcomes, documentation, and utilization review.
• Collaborates with Leadership to implement and monitor clinical initiatives; develop clinical indicators / diagnostic criteria for diagnoses.
• Must maintain an active clinical load of at least 20%.
• Performs other duties as assigned

Reporting Relationship

Reports to the Chief Medical Officer

Minimum Qualifications

• Doctor of Medicine (MD) or Doctor of Osteopathy Medicine (DO) from an accredited college or university
• Licensed as a physician in the State of Illinois prior to starting employment
• Must be cleared for privileges by Medical Staff Services by start of employment
• Board certification in respective medical specialty
• Five (5) years of clinical practice experience in a large health care system or group practice
• Three (3) years of Utilization Management experience with two (2) years of experience as a Physician Advisor
• Two (2) years of leadership experience within a hospital or health system
• Current Health Care Quality and Management Certification (CHCQM) by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP)

Preferred Qualifications

• Experience and knowledge of the Revenue Cycle process
• Current Physician Advisor Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP)

Knowledge, Skills, Abilities and Other Characteristics

• Knowledge of current health care regulation, accreditation and licensure requirements for physicians and facilities
• Knowledge of Quality Management, Utilization Management, documentation processes and program structure
• Knowledge of utilization, case management, clinical documentation, and quality guidelines
• Knowledge of applicable Federal, State, and local laws and regulations, Corporate Integrity Program, Code of Ethics, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior
• Knowledge of a broad range of medical / surgical diagnoses, treatment modalities, therapeutic services, and intervention techniques
• Knowledge of quality improvements processes and the ability to implement them
• Knowledge of the principles and methods of training medical staff to ensure standards of care
• Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
• Excellent program development, management. and leadership skills
• Strong supervisory and leadership skills necessary to oversee attending physicians
• Strong interest and skills in medical education
• Demonstrate analytical, problem-solving, critical thinking. and conflict management / resolution skills
• Strong organizational skills and mastery of a content domain, as demonstrated by successful quality improvement initiative or program execution
• Skill to builds cooperative relationships and alliances throughout the organization and relates to all levels and classifications of employees

Knowledge, Skills, Abilities and Other Characteristics continued

• Ability and willingness to effectively approach physicians on issues related to quality, documentation and utilization as needed
• Ability to make sound decisions based on criteria of Medicare / Medicaid, other payers and / or other utilization / reimbursement agencies regarding medical necessity and the quality, appropriateness, and efficacy of patient care
• Achieves excellence by being action oriented, decisive and follows through and aligns resources to accomplish objectives
• Demonstrated how to use effective strategies to facilitate change initiatives and overcome resistance to change
• Ability to understand, incorporate, and demonstrate the mission, vision, and values of CCH in leadership behaviors, practices, and decisions
• Ability to understand complex issues and develops solutions that effectively address problems.
• Ability to understands the role of emerging technology and its impact on operational effectiveness and organizational change
• Strong ability to mentor and develop medical professionals
• Strong ability to manage schedules, budget, and personnel

Physical and Environmental Demands

This position is functioning within a healthcare environment.The incumbent is responsible for adherence to all hospital and department specific safety requirements.

This includes but is not limited to the following policies and procedures : complying with Personal Protective Equipment requirements, hand washing and sanitizing practices, complying with department specific engineering and work practice controls and any other work area safety precautions as specified by hospital wide policy and departmental procedures.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification.

They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.

FILING.

Degrees awarded outside of the United States with the exception of those awarded in one of the United States’ territories and Canada muse be credentialed by an approved U.

S. credential evaluation service belongings to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE).

Original credentialing documents must be presented at time of interview .

• Please note all offers of Employment are contingent upon the following conditions : satisfactory professional & employment references, healthcare and criminal background checks, appropriate licensure / certifications and the successful completion of a physical and pre-employment drug screen.
• CCH is strictly prohibited from conditioning, basing or knowingly prejudicing or affecting any term or aspect of County employment or hiring upon or because of any political reason or factor.

COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER.