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Job Summary:

The Medical Director of Utilization, Clinical Documentation and Care Coordination will serve as a liaison between clinical staff, payers, and administrative personnel to conduct clinical reviews on cases to meet regulatory requirements in accordance with organizational objectives for assuring quality patient care and effective, efficient utilization of health care services. This physician will provide guidance and expertise related to medical necessity of care, assessment of resource utilization, compliance, and improved clinical documentation processes. The physician is expected to focus on patient quality and safety, billing status determinations, clinical documentation, patient length of stay and utilization management (including appeals). The physician will be expected to provide clinical and administrative leadership, as well as serve as an organization educator with supervisory duties.

Essential Functions and Responsibilities:

Specific duties may include but will not be limited to:

• Engaging in physician-to-physician communication to provide just-in-time education and resolving conflicts regarding utilization concerns and clinical documentation education. Educating staff and providers regarding ICD-10 documentation requirements.
• Helping to oversee and provide mentorship to providers regarding utilization and clinical documentation.
• Guiding documentation training for physicians individually or in group settings.
• Educating medical staff on the importance of complying with hospital policies and regulations; explaining specific policy or regulation changes.
• Participating in Utilization Review Committee and being a member of appropriate committees and teams to improve utilization, care transitions and appropriate clinical documentation as assigned.
• Performing Physician Advisor role in determining and arbitrating level of care determinations: performing Peer-to-Peer reviews with insurance companies that are denying an inpatient level of care or completing second level reviews for patients not meeting inpatient criteria.
• Mediating case conflicts between different hospital departments, care teams, or other staff members.
• Aiding hospital staff in preparing documentation for Medicare compliance audits.

Qualifications:

• Medical Degree MD or DO
• BC Internal Medicine, Family Medicine
• Virginia Licensed Physician or eligible
• Minimum one year as a Physician Advisor with inpatient practice experience
• Experience practicing medicine, preferably as an Adult Hospitalist
• Strong Documentation and Coding standards
• Strong Interpersonal skills
• Ability to build strong relationships.
• Diplomatic, Negotiation and peace keeping skills.

As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.