Medical Director

Job Summary and Qualifications

The Medical Director serves as a clinical resource and consultant to hospitals by providing identification, facilitation, and resolution of denials. The Medical Director will be responsible for timely completion of assigned peer to peers and documentation of the outcomes. The Medical Director will also provide physician education regarding accurate determination and documentation of the admission status/level of care and presence of complications or comorbidities.

ESSENTIAL JOB RESPONSIBILITIES:

• Conducts peer to peers with health plan counterpart for denied inpatient cases.
• Acts as a liaison with payers to facilitate approvals and prevent any denials. Facilitates, mentors, and educates other physicians regarding payer requirements.
• Performs data analysis related to utilization review (UR) metrics, works with hospital utilization management committees upon request to develop, implement, and monitor action plans related to denial reduction and authorization of level of care.
• Offers input on managed care contracting issues, best demonstrated practices, process improvement and utilization management activities, barriers to achieving goals and objectives of initiatives, and denials prevention initiatives.
• Demonstrates leadership, collaboration, and effective communication skills.
• Participate in the concurrent and retrospective appeal peer-review process. Provides oversight to the pre bill denial strategy within the payer process. Schedules and manages meetings with payer medical directors for collaboration and process improvement. Functions as a core team member of the denial management team. Educates physicians about ICD coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records.

REPORTS TO: VP Physician Advisor Peer to Peer Services

POSITION QUALIFICATIONS:

• Licensed (or eligible for licensure) Physician (MD/DO) in a state in the United States.
• Board Certification Required (Internal Medicine and Family Medicine preferred) Preferred ABQAURP HCQM Board Certification.
• Preferred work experience with the payors or as a physician advisor.

EDUCATION AND EXPERIENCE:

• Minimum of 5 years of experience in clinical practice.
• 3 years prior experience working for Payor, Physician Advisor or in a Leadership role.
• Knowledge of InterQual, Milliman or related evidenced based criteria sets.
• Familiar with Joint Commission, State and Federal standards/requirements, and DRG vs Per diem reimbursement models.
• Knowledgeable about third party payer source criteria of medical necessity.
• Organized and able to meet deadlines consistently.
• Computer experience required with skills including but not limited to Microsoft Windows, spreadsheets, and word processing.

HCA Healthcare is a comprehensive healthcare network where 280,000 people across more than 2,000 care facilities are all committed to creating a positive impact every day. It’s an organization that exists to give people healthier tomorrows. Our scale enables caregivers to deliver great outcomes for patients and gives colleagues unparalleled opportunities to learn and grow. Most importantly, as a part of HCA Healthcare we’re connected to something bigger, which means more resources, more solutions and more possibilities for everyone who walks through our doors. What matters most to our diverse and talented colleagues is giving people the absolute best healthcare possible. Every day, we seek to raise the bar higher, not just for ourselves, but for healthcare everywhere.

We offer an excellent total compensation package, including competitive salary, excellent benefit package and growth opportunities. We believe in our team and your ability to do excellent work with us. Your benefits include 401k, PTO, medical, dental, flex spending, life, disability, tuition reimbursement, student loan repayment program, employee discount program and employee stock purchase program. We would love to talk to you about this fantastic opportunity.