Utilization Review Medical Director

Position Details

Department: PCH-MAIN | Case Management
Category: Unclassified
Location: Phoenix
Employee Type: Regular
Posting #: 317702
Posted On: 12/12/2016

Position Summary

The Medical Director, Utilization Review (UR) is responsible for helping to manage the quality and efficiency of care delivered at PCH by working with senior leadership, medical staff and the departments of social work, case management and utilization management as well as the Hospital Revenue Cycle management team. By developing and implementing methods to optimize use of hospital services for all patients, the Medical Director, UR helps to ensure the quality of care provided at PCH. The Medical Director, UR also participates in the development of case management protocols, works with physicians and the health care team to optimize length of hospital stay, ensures patients are in the appropriate level of care and monitors the appropriate use of diagnostic and therapeutic modalities. Through these efforts, the Medical Director, UR plays a key role in helping PCH achieve its desired resource management, compliance and quality and safety goals.

Position Duties

  1. Utilization Management
    • The Medical Director, UR is the Chair of the Utilization Review Management Committee (URMC). When this committee identifies specific physicians that require intervention for consistently poor utilization of resources, the UR will follow the URMC process. The UR is also available as a support to the utilization management nurses for insurance review issues. The UR collaboratively works with the Director of Care Management in the development of the case management, utilization management and social work teams.
  2. Denial Management
    • The Medical Director, UR is available to assist the case management/utilization review team by reviewing medical records in order to clarify clinical information not present in the medical record. The UR is also available to assist with peer to peer discussions with third party payer medical directors. The UR participates in all levels of denial management including state fair hearing and serves as an expert witness during the proceedings.
  3. Relationships with Third Party Payers
    • The Medical Director, UR develops and maintains positive relationships with third-party-payers and ensures processes are followed according to policies and contracts. The Medical Director, UR and the Director of Care Management attend regularly scheduled meetings with health plan medical directors as well as quarterly JOC meetings. The Medical Director, UR focuses on overturning denials, proactively addressing recurrent denial themes and serves as a resource to the PCH contract team.
  4. Assigning the Appropriate Level of Care
    • The Medical Director, UR possesses detailed knowledge about the appropriate levels of care and advises the medical staff, case management and utilization management teams in the appropriate use of these levels of care. The Medical Director, UR (with the URMC) regularly reviews data at different levels of care to determine whether consistent patterns of inappropriate level of care assignment exist for certain providers of care or for certain clinical populations. Should a change be needed the UR will follow the URMC process in order to educate the identified providers.
  5. Discharge Planning Support
    • The Medical Director, UR is available to support the social work, case management and utilization management teams when there is a lack of agreement between the social work, case management, and utilization management teams and the attending physician with regards to discharge planning or transfer to a lower level of care.
  6. Collaboration with the Phoenix Children’s Care Network (PCCN)
    • The Medical Director, UR collaborates with PCH’s clinically integrated network, PCCN. Such collaboration will include creation and implementation of transition of care protocols, appropriate utilization of services during acute care encounters and creation and implementation of clinical protocols and pathways.
  7. Performs miscellaneous job related duties as requested.

Phoenix Children's Mission, Vision, & Values

Mission

To advance hope, healing and the best healthcare for children and their families

Vision

Phoenix Children's will be the leading pediatric health system in the Southwest, nationally recognized for exceptional care, innovative research and advanced medical education.

We realize this vision by:

  • Offering the most comprehensive care across ages, communities and specialties
  • Investing in innovative research, including emerging treatments, tools and technologies
  • Advancing education and training to shape the next generation of clinical leaders
  • Advocating for the health and well-being of children and families
Values
  • We place children and families at the center of all we do
  • We deliver exceptional care, every day and in every way
  • We collaborate with colleagues, partners and communities to amplify our impact
  • We set the standards of pediatric healthcare today, and innovate for the future
  • We are accountable for making the highest quality care accessible and affordable
The position has been closed or filled.

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