Medical Director of Utilization Management HRMC FT PC14465
Health First, Incorporated - Melbourne, FL

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To be fully engaged in providing Uncompromised Safety, Superior Quality, Memorable Patient/Customer Experiences, and Financial Stewardship by developing and providing a system-wide utilization management, denials prevention / management system for Health First that incorporates best practices and optimal quality/outcomes.

Primary Accountabilities

  • Serves as the leader and champion of a system-wide best practice, quality-driven utilization and denials management/prevention system for Health First
  • Maintains continuous liaison between medical staffs and Health First associates to improve and maximize safe patient outcomes and optimal quality.
  • Educates, develops processes, and monitors compliance of appropriate patient admission status and Length of Stay.
  • Teaches and assists Case Management and other Health First staff in utilization review and cost containment functions.
  • Maintains expertise in, and champions best practice / best evidence management of hospitalized patients, including quality process and outcome measures.
  • Maintains fluency in and monitor clinical/practice informatics: SCM, Midas, Crimson, CPM
  • Maintains expertise in clinical guideline systems: Interqual, Milliman and Roberts
  • Maximizes system-wide, consistent approach to quality patient management and denials prevention.
  • Retrospectively review medical records for Risk complaints regarding quality and appropriateness of care.
  • Develops and maintains relationships with medical staff physicians and Health First associates.
  • Provides backup to VPMAs when needed, and weekend cross-coverage. Manage Case Management Physician
  • Advisor real time referrals for all four HF hospitals.
  • Review and manage retrospective denial appeals for Medicare, Medicaid and other insurers.
  • Develop and monitor pre-payment review processes to include policies and procedures, education, and management of denials, emphasizing prevention of denials.
  • Support Recovery Audit Contractor case reviews and appeals.
  • Attend Utilization Management meetings, develop data metrics, provide education to staff and providers, and develop action plans for facilities and providers.
  • Maintain expertise in current regulatory requirements to optimize reimbursement.
  • Attend and/or chair Denials Management committee meetings

  • Must be licensed to practice medicine in Florida.
  • Must have two-to-three years of previous Administrative experience or other comparable broad knowledge and exposure to Utilization/ Medical Management activities.
  • Must have actively practiced medicine in his/her specialty for a minimum of five years.
  • Must have excellent rapport with physicians and members of management.
  • Must have clear and effective oral and written communication skills.
  • Must be able to see the big picture and to create and sustain structures and models that positively impact the incremental