Medical Director - Utilization Management and Document Integrity
The Medical Director works closely with the medical staff leadership, the entire medical staff, including resident physician house staff, all areas of resource management, case management, social services, discharge planning, and utilization management to develop and implement methods to optimize use of hospital services for all patients while also ensuring the quality of care provided. This includes working with hospital leadership in developing care management protocols with physicians and others to optimize length of hospital stay and efficient management of resources, insuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities.
ACUTE INPATIENT FUNCTIONS:?
- Review medical records of patients identified by case managers or as requested by the healthcare team in order to perform quality and utilization oversight
- Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews
- Assist with length of stay management and utilization of resources
- Assist with the denial management process
- Review and make suggestions related to resource and service management
- Perform reviews for determining professionally recognized standards of quality care
- Provide regular feedback to physicians and all other stake holders regarding level of care, length of stay, and potential quality issues
- Recommend and request additional and more complete medical record documentation to support placement status or medical necessity
- Review cases that indicate a need for issuance of a hospital notice of non-coverage/Important Message from Medicare (HINN). Discuss the case with the attending physician and if additional clinical information is not available, coordinate the process with the Care Manager for issuance of HINNs
- Understand and use MCG/InterQual and other appropriate criteria. Document response to case management referrals. Support Case Management in a data-driven approach
- Facilitate pre-payment reviews and/or participating in recovery audit contractor reviews
- Assist Hospital Administration in billing for the technical component of the services rendered by the Departments, including initial billings, follow-up reports, and appeals in cases of retrospective denials
- Assist Hospital Administration and the Medical Staff in connection with any regulatory audits, investigation, survey, or other review of the Departments
- Ensure consistency of utilization review services, quality control, and patient safety
- Act as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate by participating in Per to Peer discussions and reviews
- Facilitate, mentor, and educate other physicians regarding payer requirements
- Participate in review of long stay patients, in conjunction with the Care Management Leadership, Care Management team, and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care
- Participate in Interdisciplinary Rounds (IDT) with the Healthcare Team as indicated
- Provide guidance to ED physicians and ED Case Management regarding status issues and alternatives to acute care when acute care is not warranted
- Work with Care Management and an interdisciplinary team to insure appropriate continuity of care
- Participate in all organizational efforts to reduce inappropriate readmissions
- ?Conducts physician education sessions to share data, trends, practice patterns, and other relevant information as requested.
- ?Ensures physician accountability for efficient patient care management.
- Investigates avoidable delay concerns referred by case management staff that effect patients' outcomes during their hospital stay.
- Contacts physicians in a timely manner to resolve delays and achieve positive outcomes.
- Demonstrates positive outcomes through interventions with attending or consulting physicians that delay care and affect the length of stay or avoidable delays, etc.
- Identifies denial trends and works with the medical staff and hospital administration to resolve the issue.
- Reports practice pattern trends and opportunities to service line or department specific meetings at the request of the CMO, Vice President of Care Management, or hospital leadership.
CLINICAL DOCUMENTATION IMPROVEMENT SUPPORT:
- Educates individual hospital staff physicians about ICD-9 and ICD-10 and DRG coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records.
- ?Educates specific medical staff departments (e.g., Internal Medicine, Surgery, Family Practice, etc.) at departmental meetings on coding and documentation improvement guidelines.
- Explains reasons why individual physicians should be concerned about correct disease reporting and the subsequent ICD code capture of severity, acuity, risk of mortality, and DRG assignment, such as: Physician performance profiling, physician E&M payment and pay for performance, appropriate hospital reimbursement and profiling for patient care.
- Describes ways to provide improved health record documentation that specifically affect ICD code assignment capture of severity, acuity, risk of mortality, and DRG assignment.
- Develop structure and implement a clinical documentation improvement and integrity program, taking into account the makeup of your medical staff, medical process environment of the hospital, medical coder competency/skill sets, and overall strategic planning of the organization.
- Build strategies for Medicare important message compliance in collaboration with care management.
- Develop the skills for screening for medical necessity, ensuring the appropriate level of care and properly crafting clinical queries using established guidelines. Discuss how to recognize when a clinical query is needed with members of the CDI team.
- Provide strategies to minimize risk and reduce provider liability or loss of inpatient revenue.
- Build and expand upon time-tested proven strategies that contributed to the development and implementation successes of clinical documentation improvement.
- List pitfalls to avoid in the development and implementation phases of your program that will jeopardize the probability of success in and buy-in from the medical staff.
- ?Effectively communicate physician teaching points for immediate and future clinical case studies.
- Discuss the basis for discussing succinct points with physicians, upon the opportunity to present to present teaching points that stress the application of medical records documentation beyond claims data into administrative data.
- ?Explain the role of administrative data in today's business of medicine - and the future of medicine.
- ?Works with the IT Leadership team to ensure the system appropriately supports the physician's ability to provide best practice medicine by creating logical processes and providing the necessary order sets and practice guidelines.
- Participates as part of the physician advisory council to assist with clinical decisions for the EHR.
- Performs related duties as assigned.