Medical Director Process - Inpatient Care Coordination

Overview

At Presbyterian, it's not just what we do that matters. It's how we do it. How we do things here makes all the difference.

 

Presbyterian Medical Group seeks a Board Eligible / Board Certified ACGME or AOA Residency trained Physician to join our established practice in Albuquerque, New Mexico. We're all about well-being, starting with yours. We offer a nationally competitive salary with relocation allowance available, CME allowance and fully paid malpractice insurance.

 

Responsibilities

Summary:The Medical Director of Inpatient Care Coordination (Senior Physician Advisor) provides clinical leadership to the Inpatient Care Coordination Department, and is accountable for establishing utilization and quality outcomes for all hospitalized patients within the Albuquerque Delivery System. Reports to the Chief Medical Officer/Clinical Transformation Officer. Collaborates with the Inpatient Care Coordination Department Director and Care Coordination team to establish and implement clinical programs to support and meet the goals within Care Coordination Department. As Physician Advisor assists with issues such as medical necessity; compliance; level of care; length of stay; resource management; hospital reimbursement; quality issues; case management; and physician education

 

Responsibilities:*Collaborates with Executive Medical Director, Compliance, Revenue Cycle and Care Coordination Department Director to establish and implement clinical policies to support and meet the goals of utilization, revenue cycle and case management*Provides medical leadership and support to Physician Advisors, Care Coordination Department, serving as clinical resources, coach and leader*Supports Care Coordination in daily review activities, interacts with medical staff when appropriate. Documents case review findings, actions and outcomes in accordance with Care Coordination policies in the electronic utilization management system*Conducts daily and ongoing clinical review and evaluation of clinical care and services provided to hospitalized patients in acute and sub-acute facilities within theAlbuquerque Delivery System. Initiates consistent peer-to-peer dialogue to review utilization management opportunities, develops collaborative intervention plans and shares ideas regarding system issues. Accesses clinical specialty panel physicians to assist with complex or difficult patient care related issues. Conducts daily conferences by rounding with the Care Coordination team to identify delays in patient care, facilitates discharge planning, and develops follow-up action plans to address issues*Communicates and collaborates with physicians, Compliance, Revenue Cycle, Administration, Nursing and Care Coordination, streamlining policies and procedures to ensure compliance with regulatory bodies such as the Center of Medicare Services, JCAHO, and appropriate state agencies*Identifies risks or liability issues related to utilization management, works with Care Coordination Department Director, Executive Medical Director Population Health and Compliance to mitigate risks and ensure compliance standards are met mandated by the Center of Medicare Services, Joint Commisison and other appropriate regulatory bodies.*Participates in committees that focus on patient care, performance initiatives and quality measures related to utilization management. Utilizes performance data to guide interactions with medical staff. Collaborates with Medical Staff Affairs to address compliance or patient care issues related to utilization management on routine basis*Chairs Utilization Management Committee meeting, develops metrics, monitors results and develops action plans to address indicators not meeting targets. Reports utilization management metrics per the Utilization Management Plan*Interacts with Presbyterian Health Plan Leadership to ensure coordinated approaches and processes are in place specific to utilization management of PHP patients admitted to the Albuquerque Delivery System*Conduct verbal and written review and appeal of denied or downgraded coverage determinations made by managed care/commercial payors*Promote hospital adherence to ensure compliance with CMS policy regarding inpatient admissions and observation status, as well as the appropriateness of continued hospital stay.*Performs other functions as required

Credentials Required:Board certified medical doctor with completion of an ACGME or AOA residency. Strong knowledge of the Center of Medicare Services (CMS) regulations and national guidelines. Proven interpersonal communication skills and the ability to develop relationships with medical staff and other providers working within Presbyterian Healthcare and the community. Data Analysis and interpretation skills focusing on key metric. Minimum of five years experience in clinical practice. Minimum of 2 years experience as a Physician Advis