The Medical Director, Case Management (‘CMMD’) will oversee aggregate length of stay processes, readmissions initiatives, post-acute transitions, and utilization review of patient bedding status. The CMMD will review referred and selected cases for appropriateness of admission, level of care criteria, continuing stay, length of stay, medically necessary services, and appropriate post-acute disposition. In addition, the Medical Director will facilitate communication and problem resolution with attending and treating physicians through multidisciplinary work and/or direct physician contact.
The Medical Director works collaboratively with the Director of Case Management and the department staff, including Case/Care Managers, Social Workers, Referral Coordinators, Navigators, and Resource Center staff. The position is credentialed by MHMD and privileged at one or more hospitals.
The CMMD must be able to demonstrate knowledge and skills necessary to provide care management appropriate to the patient population served. The Medical Director must demonstrate knowledge of the principles of growth and development as it relates to the different life cycles.
Reviews individual cases concurrently and retrospectively, including denied cases.
Case reviews may be required independently, in multidisciplinary round collaborations, and as requested by case/care managers.
Reviews appropriateness of admission, continuing stay, medical necessity of services and safe, appropriate post-acute plan.
Reviews will employ CMS guidance, utilization management criteria sets, MHHS guidelines, Local and National Coverage Determinations, and clinical judgment.
CMMD’s will be expected to apply professional judgment and review patient-specific variables on reasonable and necessary care.
Serves as a member of the care management oversight team, acting as a key physician liaison among hospital medical staff/practitioners, hospital case management and care management/health plan partners.
Communicates with physicians to capture additional pertinent information for evaluation of medical necessity and appeal letter preparation.
Communicates with attending and treating physicians in order to resolve issues regarding patient bedding status, length of stay, appropriateness of services, transitions of care, post-acute disposition, and resource utilization in collaboration with case management staff.
Supports and participates in local and/or system MHHS communication initiatives regarding health management.
Compliance and efficiency
Assists MHHS in delivering the services in an efficient manner in compliance with applicable legal and accreditation requirements.
Stays current on Medicare and State of Texas rules and regulations and applicable payer requirements.
Advocates with staff for timely, efficient, appropriate and patient-centered care.
Advocates for patient health and an integrated, optimal end-to-end patient/member experience.
Advocates in a collaborative and team-based fashion through the chain of command.
Assessment and monitoring
Monitors the clinical and business aspects of physician advising and utilization management activities.
Reviews all routine reports and performance measures and prepares limited analysis for the purposes of informing leadership, supporting utilization management committee, and educating staff.
Makes recommendations to system, regional, department and campus leadership regarding opportunities for health management enhancement, appropriate clinical documentation practices, medically necessary resource utilization, denial avoidance and length of stay improvement.
Collaboration with leadership
Work collaboratively with the care and case management directors on utilization committee preparation, on concerted approaches to utilization improvements for clinical services, on complex and outlier cases, and on standardization interdisciplinary review and collaboration.
Works to ensure medical staff leadership, CMO(s) and UM Committee chairs receive timely information and updates on the efforts of physician advisors.
The CMMD may serve as Vice Chair or Co-chair of the Utilization Management Committee, in support of committee leadership and other medical staff participants.
Formulates medical necessity and appeal letters with Case Management, UM Committee leadership and other leadership as necessary.
Reviews medical necessity appeals letters and follows the appropriate procedures.
Assists in the development, implementation and carrying out of performance improvement and quality assessment efforts related to case management and care management.
Provides ongoing education and information to medical staff and care/case management staff regarding best practices, organizational structures and functions, use of clinical guidelines, appropriate levels of care, documentation, and relevant new regulation.
Participates in care coordination pathway development and workflow innovations through the Clinical Program Committees and Service Lines.
Safety, Standards and Development
Participates in relevant professional development organizations as approved by supervisor.
Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
Other duties as assigned.
What does it mean to truly connect with a patient? You’ll find out as part of the Memorial Hermann Health System. Here, you’ll have the unique opportunity to utilize the latest technical advances in medicine while also benefiting from our insights into the human aspects of care. You’ll serve each patient as an individual, and you’ll help develop their own personalized plan of care.
Every day, you’ll be empowered to do what’s best for them while also advancing your own skills. If you want to explore a change in your career, we encourage it. In fact, we celebrate it. Your mentors will guide your growth, your co-workers will encourage your success and your career will be built the way you want. We invite you to follow your dreams and lead with compassionate care.
Education: Medical Doctorate (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school required; Additional education and/or experience in the areas of management, utilization and/or quality preferred
Licensed to practice as MD or DO in the state of Texas
Board certification in primary care or medical specialty area is preferred
Experience / Knowledge / Skills:
Five (5) years experience in clinical setting
Current staff privileges at one or more MHHS hospitals preferred
Ability to work collaboratively to achieve established goals and exercise independent judgment with minimal supervision or oversight
Recognition by peers as an outstanding clinician
Proven capability to communicate and to develop positive relationships with physician colleagues and non-physician staff
Working knowledge of regulatory, payer and utilization management issues
Demonstrated accuracy and understanding of medical documentation and coding
Strong interpersonal, analytical and organizational skills
Incumbent must demonstrate objectivity, flexibility and tact in dealing with potentially sensitive medical staff issues, practice patterns, and clinical resource utilization
Effective oral and written communication skills
Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann and an optimal end-to-end health experience.
Internal Number: 100104088
About Memorial Hermann Health System
At Memorial Hermann, we’re about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care.
Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.