As the physician advisor, the Executive Medical Director of Revenue Cycle educates, informs, and advises members of the Utilization Management, 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 all 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 Executive 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. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
KNOWLEDGE AND SKILLS REQUIRED:
- 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, balancing the needs of the business and the interest of patients and member physicians alike
- 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
- Handle a high volume of denials and proactively handle with proficient skills
- Graduate from medical school and residency program
- Master’s degree in Business or Healthcare Administration
- Minimum of ten years recent clinical practice experience
- Minimum of seven years of leadership experience
- Understanding of Hospital Care Management, including Utilization Management
- Two years or greater experience as a Physician Advisor
LICENSURE, CERTIFICATION, OR REGISTRATION REQUIRED:
- Current, valid State of Florida physician license
- Board certified and eligible for membership on the Hospital medical staff
PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:
Demonstrates, through behavior, AdventHealth’s core values of Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork
SCOPE OF RESPONSIBILITY:
- Responsible for reviewing and authorizing inpatient days and the evaluation of inpatient utilization patterns within service areas to identify areas of improvement, developing specific strategies and criteria addressing areas of need. Collaborates with Senior Medical Officers with contracted managed care payers regarding utilization review management activities and maintain a positive and supportive relationship between the inpatient facilities, health plans and physicians (hospitalist groups and primary care providers), as well as interdepartmental liaison for ACO activities and program development. 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. Provides support, shares administrative call, and maintains collaborative relations with the other medical directors.
- Participates with the Medical Directorate to review and develop medical guidelines and policies. Advise and educate Care Managers regarding clinical issues. Act as liaison for and attending physicians to arrive at most appropriate inpatient/outpatient utilization determinations. Assists in other duties related to utilization review and quality improvement of the network as assigned by the Division CFO/Sr VP, Vice President of Revenue Cycle Operations and/or Director, Utilization Review Management.
- Reviews data and trends to identify opportunities for utilization improvement to positively influence practice patterns. Conducts regular, ongoing meetings with Care Managers to ensure continuity and efficiency in the inpatient setting. Performs other duties as assigned. Develops clinical care pathways and utilization benchmarking for specialty groups within the Orlando market. Manages specialty-specific quality screens and utilization outliers.
- Collaborates and develops relationships with payers and the community health resources. Actively contributes in efforts to monitor and reduce unnecessary length of stay. Participates in review of long stay patients, in conjunction with the Director of Utilization Review Management to facilitate the use of the most appropriate level of care. Provides education and serves as a resource to Medical Staff colleagues regarding best practices, Care Management structure, and functions and uses of clinical guidelines. Develops and facilitates productive internal/external relationships with all physicians and constituents of Care Management.
- Acts as a liaison between contracted Managed Care/Commercial payers related to managed care denials, Care Management and the Hospital’s Medical Staff to facilitate the accurate and complete documentation for coding and abstracting of clinical data, capture of severity, acuity and risk of mortality, in addition to DRG assignment. Establishes and maintains a presence within the Medical Staff structure and active participation on applicable committees (i.e. JOC/Payer, Revenue Cycle, Finance Committee, etc.).
Operating & Capital Budget/Financial Responsibility:
Performance Improvement Responsibility:
Community Relations Responsibility: