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To be responsible for understanding and assisting in maintaining a compliant and effective case management, utilization management and discharge planning process and program. Supports and participates in the process for identification of medical necessity for patient hospitalization, utilization of resources and quality of care through the secondary medical record review process.


• Provides 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. Acts as a resource for the medical staff regarding utilization management and discharge concerns as well as federal and state utilization and quality regulations. Discusses and educates 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. Provides a daily source of feedback regarding utilization and quality concerns to the Case Management and supports problem solving efforts by helping interpret and analyze clinical information related to criteria and level of care determination based on medical necessity.
• Performs and documents focused chart reviews as requested by individual Case Managers using clinical criteria and medical judgment to confirm/determine level of care, admission and continued stay necessity as well as to identify areas for improving utilization practices.
• Interacts with physicians regarding clinical resource issues and whose patients do not meet criteria for admission, continued stay, or level of care as needed and requested by the Case Managers. Provides guidance to ED Physicians regarding status issues and alternatives when inpatient acute care is not warranted. Provides feedback to attending and consulting physicians regarding level of care, length of stay, coordination of care and evidenced-based medicine indicators, and quality issues. Seeks additional clinical information from attending and consulting physicians and discusses the case with the attending physician as warranted and if additional clinical information is not available, discusses the process for issuance and appeal to the physician. Recommends and requests additional, more complete, medical record documentation.
• Assists Case Managers in communicating with payer representatives when a physician’s participation would support and enhance the interaction to prevent denials and advocate for the patient.
• Promote hospital adherence to ensure compliance with CMS policy regarding inpatient admissions and observation status, as well as the appropriateness of continued hospital stay.
• Rounds with selected Case Management Staff daily and participates in weekly review of long stay patients to facilitate effective case management and utilization management practices.
• Works with the Case Management and Interdisciplinary teams to prevent and reduce readmissions.
• Mentors and provides education to Case Management and Medical Staff regarding utilization management, case management, and clinical issues to support an effective utilization management program. Makes presentations to Case Management and Medical Staff, Board and Administration as warranted.
Serves on the Utilization Management Committee and assists with the annual evaluation of the hospital Utilization Management program.

JOB SPECIFICATIONS (Minimum Requirements)

1. Graduate from a recognized and accredited medical school is required. Additional education in utilization and quality management through continuing medical education and study.
2. Licensed physician in the State of Indiana.
3. Five (5) years of progressively responsible recent work experience in clinical practice or a closely related field is required.
4. Member of a Utilization Management committee or past Physician Advisor experience is preferred.
5. Ability to provide Full Time services and availability (i.e., does not maintain an external individual physician practice)
6. Maintains current knowledge of Utilization Management and Case Management. Is knowledgeable of federal, state, and payer regulatory and contract requirements. Understands and uses InterQual and other appropriate criteria. Attends continuing education sessions pertaining to utilization and quality management.
7. Maintains confidentiality and privacy of all data, records, forms and reports regarding the patient.
8. Maintains positive customer relations by using effective communication skills in all levels of communication (verbal, written, and body language) at all times.

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