The Medical Director, Utilization Management conducts clinical reviews on cases referred by care management and the clinical documentation improvement specialist (CDIS) staff and/or other health care professionals to meet regulatory requirements and in accordance with the hospital(s) objectives for assuring quality patient care and effective, efficient utilization of health care services. The Medical Director, Utilization Management meets with care management, CDIS and the health care team members to discuss selected cases and make recommendations for care, interacting with medical staff members and medical directors of third party payers to discuss the needs of patients and alternative levels of care. The Medical Director, Utilization Management acts as consultant to and resource for, providers regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources. The Medical Director, Utilization Management further acts as a resource for the medical staff regarding federal and state utilization and quality regulations.
KNOWLEDGE, SKILLS AND ABILITIES
Individuals must possess the knowledge, skills and abilities listed or be able to explain and demonstrate that the individual can perform the essential functions of the job, with or without reasonable accommodation, using some other combination of skills and abilities and possess the necessary physical requirements with or without the aid of mechanical devices, to safely perform the essential functions of the job.
- Physical requirements include the ability to raise objects from a lower to a higher position or to move objects horizontally from position to position; the ability to extend hand(s) and arm(s) in any direction; pick, pinch, type or otherwise primarily work with fingers; perceiving attributes of objects such as size, shape, temperature or texture by touching with skin, particularly that of fingertips; use upper extremities to exert force in order to draw, haul, or tug objects in a sustained motion; to press against something with steady force in order to thrust forward, downward or outward; apply pressure to an object with the fingers and palm; ability to substantially move writs, hand and/or fingers; bending body downward and forward by bending spine at the waist; bending body downward and forward by bending leg and spine; ability to bend legs at keen to come to rest on the knee or knees.
- Ability to express or exchange ideas by means of the spoken word. Essential functions include activities in which incumbent must convey detailed or important instructions to patients, physicians, families and other employees.
- Ability to receive detailed information through oral communication and to make fine discrimination in sound.
- Ability to exert up to 20 pounds of force occasionally and/or a negligible amount of force to move objects.
- The incumbent is subject to hazards including a variety of physical conditions such as proximity to moving mechanical parts and electrical currents or exposure to chemicals.
- The incumbent is subject to normal inside environmental conditions.
- The incumbent is not substantially exposed to adverse environmental conditions.
- Visual acuity sufficient for work which deals largely with preparing and data and figures, accounting, transcription, computer terminal operation, and extensive reading.
- Requires the ability to plan and perform diversified duties requiring an extensive knowledge of a particular field and the use of a wide range of procedures. Involves the exercise of judgment in the analysis of facts and conditions regarding individual problems or transactions to determine what actions should be taken with the limits of standard practice.
- Individuals are required to refrain from participating in any activities that could be construed as fraud and abuse. Requires the ability to follow the Catholic Medical Center Code of Conduct in any instance where they feel there is suspicion of fraud or abuse. Responsible for detecting offenses by employees within ones department.