Advocate Aurora Health
- Develops and contributes to the achievement of organizational goals related to providing efficient care. Participates and leads performance improvement initiatives in this area. Maintains accountability for achieving care management outcomes and fulfills obligation and responsibilities of role to support medical staff in clinical progression of patient care.
- Promotes efficient and appropriate use of health care resources across the continuum. Reviews outlier cases and recommends actions to expedite the appropriate outcomes.
- Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, appropriate diagnostic terminology to describe accurate clinical picture of patient, alternative levels of care, community resources and end of life care. Conducts physician education sessions utilizing reports with clinical and financial information to mentor physicians.
- Serves as consultant and resource to Medical Directors of Care Management and attending physicians regarding their decisions relative to appropriateness of hospitalization, level of care selection, continued stay, duplicate and/or unnecessary testing, and discharge planning. Facilitates internal and external relationships with all physicians and constituents of care management.
- Conducts clinical review as appropriate on cases referred by Care Management/Social Work/Utilization Management staff, Medical Directors of Care Management and/or other health care professionals to ensure quality patient care and effective, efficient utilization of heath care services, appropriate level of care, and monitors the appropriate use of diagnostic and therapeutic modalities.
- Demonstrates knowledge of medical necessity criteria and ICD-10 guidelines. Maintains current knowledge of federal, state and payer regulatory and contract requirements. Attends continuing education sessions pertaining to utilization and quality management.
- Acts as a liaison with payers to facilitate approvals and prevent denials. Acts as consultant and resource to all Medical Staff regarding federal and state utilization and quality regulations.
- Serves as the Physician leader to facilitate physician engagement and participation in the CDI program across the system. Promotes consistent and accurate physician documentation to support the patient's level of care and appropriateness of MS-DRG/DRG assignment. Provide clinical insight and knowledge for CDI program growth.
- Assist with the denial management process and related process improvement opportunities for the system and sites.
- Collaborates closely with site Medical Directors of Care Management and Site CMOs on system care management initiatives.
- Performs human resources responsibilities for staff which include interviewing and selection of new employees, promotions, staff development, performance evaluations, compensation changes, resolution of employee concerns, corrective actions, terminations, and overall employee morale.
- Develops and recommends operating and capital budgets and controls expenditures within approved budget objectives.
- Responsible for understanding and adhering to the organization's Code of Ethical Conduct and for ensuring that personal actions, and the actions of employees supervised, comply with the policies, regulations and laws applicable to the organization's business.
- Doctorate Degree in Medicine. Typically requires 7 years of experience in Clinical Documentation Improvement and Utilization Management as a member of the UM oversight committee or past Physician Advisor experience preferred. Additional education in Quality, Utilization Management and documentation improvement/integrity through continuing medical education programs and self-study. Knowledge of national medical necessity criteria and ICD-10 coding. Prior clinical experience.
Knowledge, Skills & Abilities Required
- Uses diplomacy and negotiation skills in peer interactions regarding utilization issues. Willing to be accountable for Key Result Areas related to but not limited to managing length of stay, resource utilization (cost), readmissions, mortality, and the balancing of organization goals related to finance and quality Utilizes computer based medical record and other electronic tools in conduction reviews, reviewing data, and documenting as appropriate to role. Ability to travel to various hospitals and Advocate Aurora locations. Basic computer skills typing 25-20 wpm preferred Must have strong analytical and decision making skills Must be motivated and self-directed and possess qualities of leadership, interpersonal skills and the ability to communicate effectively.
- Medicine and Surgery, MD-DO license issued by the state in which the team member practices, and Physician board certification issued by an appropriate board recognized by the American Board of Medical Specialties or the American Osteopathic Association.
Physicial Requirements and Working Conditions
- This position requires travel, therefore, will be exposed to weather and road conditions. Operates all equipment necessary to perform the job. Exposed to a normal office environment. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.