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Medical Director--Utilization/Case Management

Work Schedule/Days:  Variable / Saturday; Sunday
Employment Type:  Part-Time
Location:  Office Park (1644) 
Requisition #:  32598

 

JOB SUMMARY

Provides administrative medical leadership and oversight to Utilization/Case Management, Patient Access, Patient Financial Services, Coding and Compliance for the managed care reimbursement review and appeal process.  This physician will also work closely with case management to support the efforts that ensure delivery of safe, timely, and efficient discharges. 

EDUCATION
  • Successful completion of Medical School.
CERTIFICATION SUMMARY
  • Board certified and licensed to practice medicine in the state of Georgia
  • Current DEA registration
  • Meets eligibility requirements for credentialing as part of the Children’s Healthcare of Atlanta Professional Staff
EXPERIENCE*
  • No minimum experience required
PREFERRED QUALIFICATIONS*
  • Knowledge of Interqual or other clinical criteria
  • Knowledge of both physician and hospital related managed care contracts
KNOWLEDGE SKILLS & ABILITIES*
  • Demonstrated excellent written and oral communication skills
  • Ability to develop strong working relationships with Medical Directors of Managed Care Companies
  • Working knowledge of regulations governing hospitals and medical staffs, managed care and quality management
  • Excellent organizational and follow through skills
  • Demonstrates the following skills in accomplishing job duties and responsibilities:
    • Personal organization and time management
    • Human relations and teamwork
    • Personal adaptability
    • Personal motivation
    • Listening
JOB RESPONSIBILITIES*
  1. Serves as clinical resource for utilization management staff to clarify concerns related to medical necessity criteria for admission.
  2. Facilitates the secondary review process when clinical treatment or plans are in question.
  3. Serves as a liaison for the medical staff in reviewing and facilitating appropriate reimbursement for managed care patients.
  4. Provides physician education related to precertification, UR roles and responsibilities, and denial trends.
  5. Works with other Children’s and Managed Care leaders on special task forces to enhance Children’s managed care processes, procedures and operations to better manage payor agreements (e.g., uses medical literature to support Children’s positions when we see trends in denials).
  6. Evaluates reports and information as necessary to ensure proper detail of reimbursement in regards to managed care contracts and the appeals process.
  7. Identifies trends and process improvements in the denial management process.
  8. Serves as co-chair of UM Committee and participates in other relevant meetings such as Medicaid Steering committee and joint operations meetings.
  9. Provides medical leadership to case management to ensure safe, timely, and efficient discharges.
  10. Supports legal department regarding issues related to medical necessity denials and UM compliance.
  11. Meets with officials of DCH, GMF and others to support need for payment for a variety of issues.
  12. Participates in internal audits and helps ensure that Children’s UM processes are fully compliant. 
SYSTEM RESPONSIBILITIES*

Safety: Practices proper safety techniques in accordance with hospital and departmental policies and procedures. Responsible for the reporting of employee/patient/visitor injuries or accidents, or other safety issues to the supervisor and in the occurrence notification system.

 

Compliance: Monitors and ensures compliance with all regulatory requirements, organizational standards, and policies and procedures related to area of responsibility. Identifies potential risk areas within area of responsibility and supports problem resolution process. Maintains records of compliance activities and reports compliance activities to the Compliance Office.

 

The above statements are intended to describe the general nature and level of work performed by people assigned to this classification.  They are not intended to be an exhaustive list of all job duties performed by the personnel so classified.

PHYSICAL DEMANDS*
Ability to lift up to 15 lbs independently not to exceed 50 lbs without assistance
Bending/Stooping - Occasionally (activity or condition exists up to 1/3 of time)
Climbing - Occasionally (activity or condition exists up to 1/3 of time)
Hearing/Speaking - Effective communication with employees, supervisors/managers and staff. Effective communications with patients and visitors, as required.
Lifting - Occasionally (activity or condition exists up to 1/3 of time)
Pushing/Pulling - Occasionally (activity or condition exists up to 1/3 of time)
Sitting - Constantly (activity or condition exists 2/3 or more of time)
Standing - Occasionally (activity or condition exists up to 1/3 of time)
Walking - Occasionally (activity or condition exists up to 1/3 of time)
WORKING CONDITIONS*
No potential for exposure to blood and body fluids

 

Address:  1644 Tullie Circle, Atlanta, GA  30329 
Function:  Leadership/Management - Medical Director


Nearest Major Market: Atlanta

Job Segment: Medical, Manager, Case Manager, Medicaid, Healthcare, Management, Part Time