As the physician advisor, the Executive Medical Director of Revenue Cycle educates, informs, and advises members of the Case Management, Revenue Cycle, Patient Financial Services, Patient Access, AHS Managed Care departments and applicable Medical Staff of specific updates, statistical trending and/or changes related to denial prevention measures for our contracted managed care payers. The Medical Director is responsible for providing physician review of utilization, claims management, and quality assurance related to inpatient care, outpatient care/observation stays and referral services. This position supports the CMO capacities at the facilities within the Central Florida Division – South by ensuring the delivery of high-quality, efficient healthcare services throughout the continuum of care for the membership served by contracted medical group provider networks. The Medical Director is an important contact for clinicians, external providers, contracted health insurance payers, and regulatory agencies. It also serves as subject matter expert, providing clinical expertise and business direction in support of medical management programs, promoting the delivery of high quality, patient focused and cost effective medical care. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
Knowledge, Skills, Education, & Experience Required:
- Strong organization skills with attention to detail
- Excellent analytical and problem-solving skills
- Effective oral and written communication skills, with the ability to articulate complex information in understandable terms to all levels of staff
- Effective computer skills, particularly Microsoft Office Outlook, Word, Excel, PowerPoint
- Ability to work in a matrix-management environment to achieve organizational goals
- Ability to translate ethical and legal requirements into practical and sustainable policies, balancing the needs of the business and the interest of patients and member physicians alike
- Ability to provide expert medical advice
- Successful history as a practicing physician
- Strong ability to build and sustain relationships in the medical community and a corporate environment
- Health plan experience in operations
- Experience in a physician group model
- Working knowledge of Microsoft PowerPoint (Preferred)
- Graduate from medical school and residency program
- Master's degree in Business or Healthcare Administration (Preferred)
- Ten years recent clinical practice experience
- Seven years of leadership experience
- Understanding of Hospital Care Management, including Utilization Management (Preferred)
- Two years or greater experience as a Physician Advisor (Preferred)
Licensure, Certification, or Registration Required:
- Current, valid State of Florida license as a physician
- Board certified and eligible for membership on the Hospital medical staff
Demonstrates through behavior AdventHealth's Core Values of Keep Me Safe, Love Me, Make it Easy, and Own it as outlined in the organization's Performance Excellence Program.
- SCOPE OF RESPONSIBILITY:
- Responsible for reviewing and authorizing inpatient days and the evaluation of inpatient utilization patterns within service areas to identify areas of improvement, developing specific strategies and criteria addressing areas of need. Collaborates with Senior Medical Officers with contracted managed care payers regarding utilization review management activities and maintain a positive and supportive relationship between the inpatient facilities, health plans and physicians (hospitalist groups and primary care providers), as well as interdepartmental liaison for ACO activities and program development. Reviews and responds to Complaints & Indicators. Works in close coordination with the processes of the Utilization Review Management staff for continual process improvement and reporting. Reviews and makes recommendations on appealed provider claims and makes determinations for appeals & grievances from members. Provides support, shares administrative call, and maintains collaborative relations with the other medical directors.
- Participates with the Medical Directorate to review and develop medical guidelines and policies. Advise and educate Care Managers regarding clinical issues. Act as liaison for and attending physicians to arrive at most appropriate inpatient/outpatient utilization determinations. Assists in other duties related to utilization review and quality improvement of the network as assigned by the Division CFO/SrVP, Vice President of Revenue Cycle Operations and/or Director, Utilization Review Management.
- Reviews data and trends to identify opportunities for utilization improvement to positively influence practice patterns. Conducts regular, ongoing meetings with Care Managers to ensure continuity and efficiency in the inpatient setting. Performs other duties as assigned. Develops clinical care pathways and utilization benchmarking for specialty groups within the West Florida Division. Manages specialty-specific quality screens and utilization outliers.
- Collaborates and develops relationships with payers and the community health resources. Actively contributes in efforts to monitor and reduce unnecessary length of stay. Participates in review of long stay patients, in conjunction with the Director of Utilization Review Management to facilitate the use of the most appropriate level of care. Provides education and serves as a resource to Medical Staff colleagues regarding best practices, Care Management structure, and functions and uses of clinical guidelines. Develops and facilitates productive internal/external relationships with all physicians and constituents of Care Management.
- Acts as a liaison between contracted Managed Care/Commercial payers related to managed care denials, Care Management and the Hospital's Medical Staff to facilitate the accurate and complete documentation for coding and abstracting of clinical data, capture of severity, acuity and risk of mortality, in addition to DRG assignment. Establishes and maintains a presence within the Medical Staff structure and active participation on applicable committees (ie JOC/Payer, Revenue Cycle, Finance Committee, etc.).
- COMPLIANCE/REGULATORY RESPONSIBILITY:
- Educates, consults, and advises members of the Medical Staff on regulatory updates and changes related to Care Management.
- Serves as a member of the Utilization Management (UM) Committee by ensuring committee is actively reviewing and acting upon trends identified through data. Provides trend data of denials to assist in improving payer or care delivery behavior.
- OPERATING & CAPITAL BUDGET/FINANCIAL RESPONSIBILITY:
- Aid in supporting Length of Stay (LOS) and quality goals.
- Reviews concurrent payer denials and intervenes with attending and/or consulting physicians and managed care medical directors, as needed, for reconsideration and denial avoidance.
- STRATEGIC PLANNING RESPONSIBILITY:
- Provides input on developing plans for physician education to meet identified needs and provides information to members of the Medical Staff and clinical departments on Care Management guidelines and protocols.
- PERFORMANCE IMPROVEMENT RESPONSIBILITY:
- Provides teaching and guidance to key associates and physicians regarding the impact of responsible stewardship of resources and attainment of important outcomes for each patient and family.
- Responsible for managing the efficiency of inpatient care delivered in the organization and collaborates with all levels of managed care team, utilization review management, hospital executive team including the Chief Medical Officers, and leadership of medical and nursing staff.
- Serves as a liaison between the AHS Managed Care Operations, Care Management, PFS, Revenue Cycle, Utilization Review departments, Medical Staff and the Chief Medical Officers for matters related to physician practice and behaviors as they affect cost, quality, documentation and patient outcomes.
- COMMUNITY RELATIONS RESPONSIBILITY:
- Develops and fosters relationships with community post-acute care partners to ensure effective communication on patient's continuum of care practices resulting in optimum patient outcomes