Posted Under: Reno, Nevada jobs in Healthcare; Healthcare jobs in zipcode 89501
Posted On: 2019-01-13 00:00:00
Position Purpose: This position acts to ensure the appropriate and efficient medical management of cases while assuring the quality of care is upheld as it relates to the primary and secondary review process. The candidate will provide guidance on both an individual case and aggregate level to cultivate efficiency related to patient care delivery providing medical case review, utilization and quality review and submit recommendations, advice and liaison services concerning quality and cost-effective patient care. Nature and Scope: The incumbent conducts clinical review on cases referred by Case Transitions staff, Utilization Management staff and/or other health care professionals in accordance with the hospital's objectives for assuring quality patient care and effective, efficient utilization of health care services, appropriate level of care, monitoring the appropriate use of diagnostic and therapeutic modalities, and to meet regulatory requirements. Incumbent will interact with clinical staff members, Medical Directors (internal and external) to discuss the needs of patients and alternative levels of care; act as a consultant and resource to attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay and use of resources; act as a consultant and resource to the clinical staff regarding federal and state utilization and quality regulations. Specific areas of responsibility include, but are not limited to: Medical Necessity Reviews/Compliance: Conduct 2nd level medical necessity reviews for all cases that do not meet first level screening criteria Provide recommendations to case managers and physicians regarding inpatient admissions, outpatient and observation services or cases not appropriate for hospital level service Review/sign condition code 44 cases Participate actively in UM Committee meetings Physician Champion: Communicate with physicians when difficult issues arise and when conversations concerning resource utilization are needed. Facilitate process of engaging physicians to provide input on medical necessity denials Conduct peer-to peer discussions with medical directors as needed for concurrent denials Assist in education of physicians regarding Clinical Documentation Improvement Program, regulatory issues, compliance issues and medical necessity. Collaborates to effectively and compassionately serve our patients, each other and the community. HIM/Coding/CDI/LOS/Throughput Serve in an advisory capacity to staff regarding appeals of denied cases, analysis of PEPPER reports, LOS and throughput projects, and CDI issues. Incumbent will have a solid understanding of hospital throughput and designations of inpatient status, observation service, and extended recovery. Incumbent must have an understanding of medical protocols and criteria and how they impact status determination Incumbent must have the understanding of clinical protocols, reimbursement challenges, and managed care principles. Incumbent must have working knowledge of electronic health records systems and experience with Microsoft Office. Additional responsibilities may be required. This position does not provide patient care. The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job. Minimum Qualifications: Requirements - Required and/or Preferred Education: MD, DO required. Graduate of an accredited Medical School. Masters in Business Administration or Masters in Healthcare Administration preferred. Additional education in Quality and Utilization Management through continuing medical education, programs and self-study. Experience: Experience 5 years of increasingly responsible experience in healthcare. Utilization Management experience or past Physician Advisor experience preferred. License(s): Licensed physician Certification(s): Computer / Typing: Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.