Medical Director-Case Management

General Summary

Responsible for optimizing healthcare service utilization while upholding the highest standards of patient care. This role requires collaboration with providers, clinical teams, and utilization management staff to ensure appropriate resource allocation, adherence to evidence-based care, and compliance with payer guidelines. This position also includes part-time work as a physician advisor.

Duties and Responsibilities

Essential Functions:

• Responsible for maintaining a 365-day Physician Advisor coverage schedule across all WellSpan acute care hospitals.
• Monitors workload and assigns team members to specific duties daily to meet the needs of each facility.
• Provides multiple avenues for team communication and updates, including weekly emails and summaries of Physician Advisor (PA) meetings.
• Manages recruitment, onboarding, and ongoing performance of physician advisors.
• Conducts and oversees periodic inter-rater reliability reviews.
• Supports and maintains active communication channels with the physician advisor team through weekly and ad hoc meetings.
• Attends and provides medical director support to all WellSpan system and entity Utilization Management (UM) Committees.
• Collaborates with the UM manager to track written appeals and update documents as needed.
• Works with the Associate Chief Medical Officer to perform medical director reviews of surgical prior authorizations lacking financial clearance.
• Regularly performs chart audits to enhance compliance, reliability, and efficiency of UM and physician advisor processes.
• Collaborates with external vendors to improve UM performance and related compliance and financial outcomes.
• Oversees data collection and reporting of Physician Advisor-related performance metrics; analyzes utilization data to identify trends, variances, and opportunities for clinical intervention.
• Conducts monthly audits of Slicer Dicer UM data to identify and correct documentation errors.
• Develops data dashboards and oversees UM data governance in collaboration with UM leadership.
• Ensures adoption of innovative tools, such as predictive models and AI, to enhance the efficiency and outcomes of the physician advisor and UM teams.
• Provides ad hoc analytics support and reporting within the scope of the UM plan to other service lines and departments.
• Maintains close contact with WellSpan hospital facility leadership, including the President and Vice President of Medical Affairs.
• Provides oversight of Quality Assurance Physician Advisor functions and reports trends or issues with clinical documentation.
• Collaborates with the Case Management (CM) and finance leadership teams to provide guidance on trends in care management and regulatory compliance.
• Educates and mentors physician advisors, physicians, clinical staff, and the UM team on best practices, payer guidelines, and evidence-based care strategies.
• Conducts training sessions on utilization review processes and policies for providers and other stakeholders as needed.
• Performs all duties of a physician advisor when fulfilling that role on a part-time basis.

Common Expectations:

• Fully documents review activities according to outlined CM policy and denial process.
• Utilizes Medicare guidelines as the basis for determinations. Follow contractual guidelines for contracted commercial payers as indicated.
• Provides daytime physician advisor coverage with availability in person or by phone 8-5p during business days unless taking PTO.
• Follows established policies and procedures of WellSpan Case Management.
• Handles patient identifying information in a secure fashion within communications.
• Acts in a professional manner and uses a "Just Culture" approach to his/her interactions with the hospital and medical staff.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

Qualifications

Minimum Education:

• Doctor of Medicine (MD) Required or
• Doctor of Osteopathic Medicine (DO) Required

Work Experience:

• 5 years Clinical experience in hospital medicine. Required
• Experience with peer review and/or case management. Preferred and
• Family Medicine, Internal Medicine, Emergency Medicine or General Surgery background specialties. Preferred

Licenses:

• Licensed Medical Physician and Surgeon Upon Hire Required or
• Licensed Doctor of Osteopathic Medicine Upon Hire Required

Courses and Training:

• Diplomate of an appropriate specialty Board (e.g., Family Medicine, Internal Medicine, etc.) Upon Hire Required

Knowledge, Skills, and Abilities:

• Extensive knowledge of the WellSpan Epic functionality.