Physician - Medical Director of Utilization & Case Management - Part time

Children's Healthcare of Atlanta•Atlanta, GA

2d•Onsite

About The Position

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.

Requirements

Minimum of five years’ clinical experience in a hospital setting or other relevant experience
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
Graduate of an accredited, four-year medical school
Graduate of an accredited, post-graduate residency program in Pediatrics
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

Nice To Haves

Knowledge of Interqual or other clinical criteria
Knowledge of both physician and hospital related managed care contracts

Responsibilities

Serves as clinical resource for utilization management staff to clarify concerns related to medical necessity criteria for admission.
Facilitates the secondary review process when clinical treatment or plans are in question.
Serves as a liaison for the medical staff in reviewing and facilitating appropriate reimbursement for managed care patients.
Provides physician education related to precertification, UR roles and responsibilities, and denial trends.
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).
Evaluates reports and information as necessary to ensure proper detail of reimbursement related to managed care contracts and the appeals process.
Identifies trends and process improvements in the denial management process.
Serves as co-chair of UM Committee and participates in other relevant meetings such as Medicaid steering committee and joint operations meetings.
Provides medical leadership to case management to ensure safe, timely, and efficient discharges.
Supports legal department regarding issues related to medical necessity denials and UM compliance.
Meets with officials of DCH, GMF and others to support need for payment for a variety of issues.
Participates in internal audits and helps Children’s UM and other leaders to maintain compliance with federal, state, and contractual requirements.