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Northwest Network Utilization Review Medical Director

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Job ID: 13907
Location: Bellingham, WA
Work Type: Full Time
Shift: Day
Shift Length: 8 Hours
FTE: 1.00
Benefit Eligibility: Full-time benefits

Job Description

Description

PeaceHealth is seeking a Northwest Network Utilization Review Medical Director for a Full Time, Day position. 


The Northwest Network (NWN) Utilization Review (UR) Medical Director is a key regional physician leader entrusted with the responsibility to optimize key hospital based resources including but not limited to utilization review, denial management, case management optimization, and capacity management for the NWN of PH. This position reports directly to the NWN Chief Medical Officer.

The NWN of PH consists of one level-2 trauma center in WA, 2 critical access hospitals (CAH) in WA and one CAH in Alaska. The NWN UR medical director serves as the dyad partner for hospital and regional case management leadership. This key physician leader will also serve in the pivotal role of a physician advisor for hospital based providers to help educate, guide, advice and recommend appropriate resource management practices for hospital based medical staff.

ESSENTIAL FUNCTIONS 

  1. Serves as the physician leader of the Utilization Management Committees across the NW network.
  2. Serves as the expert utilization management reviewer providing guidance on appropriate/alternative levels of care based on InterQual guidelines and other appropriate criteria
  3. Maintains current knowledge of federal, state, and payer regulatory requirements. Understanding and interpreting Medicare Utilization Management requirements and ensuring compliance with hospital policies and procedures
  4. Functions as a consultant to and resource for attending physicians regarding their decisions relative to appropriateness of hospitalization, continued stay, and use of resources. Provide education to and partner with physicians and other clinicians related to regulatory requirements, appropriate utilization, alternative levels of care, community resources, and end of life care.
  5. Perform concurrent and retrospective reviews of selected health records and provide feedback and education to attending physicians regarding level of care and length of stay.
  6. Acts as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate. Facilitates, mentors, and educates other physicians regarding payer requirements.
  7. Support Clinical Documentation Integrity (CDI) with education to attending physicians about ICD coding guidelines, co-morbid conditions and clinical terminology to improve their understanding of severity, acuity, risk of mortality and DRG assignments.
  8. Support CDI professionals, Hospital information management teams and the medical staff to facilitate accurate and complete documentation for coding and abstracting of clinical data, capture of severity, acuity and risk of mortality.


EDUCATION:
  • Graduate from an accredited school of medicine.

EXPERIENCE/TRAINING:
  • Experience and success in leading and facilitating groups of physicians.
  • Two years utilization management experience as a member of the UM Committee or past physician advisor experience preferred.

LICENSE/CERTIFICATION
  • Licensure as a physician in the State of practice.
  • Federal DEA number.
  • Medical Staff membership and appropriate clinical privileges at the Medical Center/Clinic.

OTHER SKILLS:
  • Excellent verbal, negotiation, and written communication skills, particularly with key stakeholder groups such as physicians, other clinicians, and quality improvement staff.
  • Strong customer service focus.

TRAVEL:
  • This is a regional leadership position serving, one level-2 Trauma center in WA, two CAH in WA and one CAH in Alaska. It is anticipated that this position will be based out of Bellingham, WA. Travel to the CAH will be required based on need. 

See how PeaceHealth is committed to Inclusivity, Respect for Diversity and Cultural Humility.  

For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state, or federal laws.

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