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Medical Director - Care Coordination, Full-time, Days

Location Winfield, Illinois Business Unit Central DuPage Hospital Job REQID 9183 Job Function Medical Director Shift Day Job (1st) Apply Now

At Northwestern Medicine, every patient interaction makes a difference in cultivating a positive workplace. This patient-first approach is what sets us apart as a leader in the healthcare industry. As an integral part of our team, you'll have the opportunity to join our quest for better healthcare, no matter where you work within the Northwestern Medicine system. At Northwestern Medicine, we pride ourselves on providing competitive benefits: from tuition reimbursement and loan forgiveness to 401(k) matching and lifecycle benefits, we take care of our employees. Ready to join our quest for better?

Description

The Medical Director, Care Coordination reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

TheMedical Director, Care Coordinationhas the authority and responsibility to carry out the Utilization Review function and is responsible for clinical reviews on cases referred by case management staff and/or other health care professionals to meet regulatory requirements and in accordance with the hospital objectives for assuring quality patient care and effective, efficient utilization of health care services. This role acts as a consultant to and resource for treating physicians regarding their decisions for appropriate level of care, continued stay, use of resources and facilitates accurate and complete documentation of clinical data that captures the severity of illness, risk of mortality and estimated length of hospital stay for inpatient physician certification. The physician advisor will also act as a liaison with the medical staff for optimization of the electronic medical record (EMR) for effective and efficient physician use.

Responsibilities:

  • Serve as co-chair of the Utilization Management Committee along with the Director Care Coordination.
  • Responsible for advancing the goals of NM with regards to quality, safety, patient satisfaction, operations and other key performance indicators, as well as financial targets within the service area.
  • Responsible for attending requested and required hospital meetings, including regularly scheduled meetings with other administrative leaders in their area
  • Advise, assist and educate treating physicians, hospital case managers (SW & RN), utilization review nurses, clinical admission nurses, senior medical management, administration and all others involved in the delivery of timely, appropriate and cost-effective patient care.
  • Promote the efficient and effective clinical care of hospitalized patients via collaborative communication and interactions with hospital clients.
  • Facilitate communication between managed care/commercial payers and providers regarding benefit coverage issues, utilization review and quality assurance processes.
  • Promote payer and provider adherence to Joint Commission standards, state regulations, and all other applicable regulatory standards.
  • Promote hospital adherence to ensure compliance with CMS policy regarding inpatient admissions and observation status, as well as the appropriateness of continued hospital stay.
  • Provide in-depth clinical expertise in the management of specific patient populations to effectively manage length of stay for hospital clients and facilitate care across the healthcare continuum by intervening as necessary to address barriers to timely and efficient care delivery and reimbursement.
  • Discuss and educate treating physicians regarding alternative courses of action or modification to the treatment plan, including but not limited to, appropriate documentation of the plan of care, to resolve utilization issues and/or ensure professionally recognized standards of quality are being met.
  • Conducts case reviews that are deemed not medically necessary for admissions or continued stay in conjunction with the treating physician and/or another member of the UM committee. Communicate the decision to the case management staff to issue written notification (HINN/ABN/commercial letter of non-coverage) to the patient and the treating physician.
  • Conduct verbal and written review and appeal of denied coverage determinations made by commercial/managed care payers, MAC, ADR or CERT audits when requested.
  • Assists in proactively reviewing assigned avoidable days and addresses these issues with individual physicians and/or practice leaders.

Qualifications

Required:

  • Remain a member in good standing of the NM CDH Medical Staff
  • Qualified by training, experience, or interest and demonstrate current ability in utilization management
  • Graduate of an accredited medical school (MD or DO)
  • 3-5 years of post-residency, clinical practice
  • Licensed physician in the State of Illinois

Preferred:

  • Board certification

Equal Opportunity

Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.

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