Medical Director Revenue Cycle

Redmond Regional Medical Center • Maitland, FL

296d • $128,961 - $193,442

About The Position

At AdventHealth Orlando, what started as a converted farmhouse in rural Central Florida has become Central Florida's major tertiary health care facility. Patients come from the Southeast, the Caribbean and even as far as South America for our proven expertise and compassionate health care. 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.

Requirements

• 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
• 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
• Graduate from medical school and residency program
• Ten years recent clinical practice experience
• Seven years of leadership experience

Nice To Haves

• Master's degree in Business or Healthcare Administration
• Understanding of Hospital Care Management, including Utilization Management
• Two years or greater experience as a Physician Advisor

Responsibilities

• Responsible for reviewing and authorizing inpatient days and the evaluation of inpatient utilization patterns within service areas to identify areas of improvement.
• Collaborates with Senior Medical Officers with contracted managed care payers regarding utilization review management activities.
• 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.
• Participates with the Medical Directorate to review and develop medical guidelines and policies.
• Advises and educates Care Managers regarding clinical issues.
• Acts as liaison for and attending physicians to arrive at most appropriate inpatient/outpatient utilization determinations.
• Conducts regular, ongoing meetings with Care Managers to ensure continuity and efficiency in the inpatient setting.
• Develops clinical care pathways and utilization benchmarking for specialty groups within the West Florida Division.
• Collaborates and develops relationships with payers and the community health resources.
• Acts as a liaison between contracted Managed Care/Commercial payers related to managed care denials.
• Educates, consults, and advises members of the Medical Staff on regulatory updates and changes related to Care Management.
• Provides input on developing plans for physician education to meet identified needs.
• Provides teaching and guidance to key associates and physicians regarding the impact of responsible stewardship of resources.

Benefits

• Benefits from Day One
• Paid Days Off from Day One
• Student Loan Repayment Program
• Career Development
• Pet Insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Industry: Ambulatory Health Care Services
• Education Level: Ph.D. or professional degree