Job ID: J122285
Company: Allegheny Health Network
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: May 21, 2018
DUTIES AND RESPONSIBILITIES:
1. Works with the Hospital and Medical Staff Executive Leaders to set, meet, and review/revise objective and subjective targets in cost, quality, and satisfaction.
2. Provides timely and effective consultation to Care Management staff to address medical necessity, patient status, level of care, medical management and/or clinical resource utilization concerns
3. Directly reviews cases to investigate above concerns, including direct contact with physicians, residents and/or physician extenders as needed
4. Responds in a timely manner to Care Management questions and other requests such as intervening with payers or the denials and appeals processes
5. Collaborates with external Physician Advisory resources as needed for education and corroboration regarding medical necessity and resource utilization practices
6. Leads or participates in Prolonged LOS weekly meetings, guiding the critical thinking to address barriers and delays in medical management and/or discharge disposition
7. Leads or participates as a member of the Utilization Management Committee and coordinates its activities with other key committees
8. Does routinely established unit rounds, minimally 3 times/week, with Case Management representative to assess and intervene to address clinical management issues
9. Provides education to physicians, residents and physician extenders regarding regulatory and payor regulations, case management or clinical resource utilization/care redesign best practices
10. Brings matters of actual or potential problems in physician practices to the CMO, the clinical services and/or administration
11. Contributes as an expert in clinical resource utilization on the development and utilization of clinical guidelines, order sets, and evidence-based best practices
12. Accesses physician experts in areas outside own expertise to bring specialty knowledge to complex situations, i.e. Infectious Disease, Psychiatry, Radiology, etc.
13. Identifies opportunities for the organization to enhance the delivery of quality, cost effective care
14. Documents according to policy.
Minimum Knowledge and Education:
• MD or DO, preferred in Medicine: Internal Medicine or Family Practice
• Oriented in principles of utilization management
• Medical necessity criteria
• Case management, utilization review processes and payer requirements
• Evidence-base best practice guidelines
Specific Skills. Abilities:
1. Clinically respected
2. Credibility with medical staff
3. Excellent communication skills with groups and individuals
4. Skilled in diplomacy, negotiation and conflict resolution
5. Time available to perform role expectations
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org