Inpatient Case Management Medical Director UnitedHealthcare Clinical Services (UCS) conducts medical management activities for commercial, Medicare and retirement, and community and state business. The majority of these activities are concentrated in inpatient review and appropriate inpatient utilization, although depending upon location and products covered, functions such as pre-certification and other traditional utilization management activities may be performed. UCS nurses, with supporting clerical staff, are concentrated in large regional centers, (although some nurses accountable to a location may work from home or onsite at network hospitals).
UnitedHealthcare's care management approach is data driven, and grounded in the use and application of evidence based medicine (EBM) and guidelines. The successful UCS medical director appreciates and understands data, is a champion of and is very conversant with evidence-based medicine, and uses nationally recognized clinical guidelines to teach and direct clinical staff, as well as engage the practicing community in discussions designed to result in individual patients receiving the right care, in the right place, at the right time.
Through daily support of the UCS nurses, the medical director serves as a primary clinical educator and mentor, and facilitates achievement of appropriate patient care goals through guiding nurses and conducting peer-to-peer communication with practicing physicians.
In addition, through the sharing of data and the promotion of EBM dialogue, the UCS medical director may engage with hospitals and/or local physician groups in forums designed to accomplish systemic change. The UCS medical director is part of a national organization and team, and will collaborate with UCS peers and nurse managers, market medical directors and others from across the country. In response to customer need and expectation, UnitedHealthcare is continuously modifying its programs and approaches. Although not a primary job function, medical directors with the interest in doing so often have the opportunity to be involved with change design and management. Responsibilities:
Is a champion of EBM, and in particular of MCG which currently are the company's primary review guidelines.
Engages daily and ongoing with line inpatient review nurses, reviewing cases electronically or in verbal case discussion, (and less often in group discussion) with the goals of achieving the delivery of the right care at the right time in the most appropriate setting. Seeks opportunities for clinically appropriate behavior change based upon EBM, and accomplishing same with the practicing community.
As a clinical resource and coach, assists nurses in having and improving insight into where and when opportunity exists. Helps nurses develop the skills and willingness to engage physicians in EBM discussion.
Develops and delivers clinical education programs that address the specific needs of the local team; instructs individual nurses to understand and apply review guidelines, as well as engage with the practicing community.
Promotes referrals to case management programs as part of longitudinal care management with the objective of reducing admissions and readmissions.
Through use and/or analysis of available data (e.g., APR/DRG), identifies more global opportunities for intervention that may 1) better focus available review resources and activities, and/or 2) change practice or hospital habit.
Assists in developing clinical strategy, identifying areas of clinical focus, developing initiatives to improve appropriate inpatient utilization and other functions and representing same to senior management.
Concisely and articulately documents case review findings, actions and outcomes in electronic systems, and meets medical director inter-rater reliability and quality guidelines.
Regularly engages in peer-to-peer dialogue with practicing physicians about the care of individual inpatients to develop collaborative intervention plans based upon EBM.
Engages with employees from other business units (e.g., market medical directors, contracting personnel) to discuss and develop strategies to promote systemic network change based upon identified operational efficiencies or gaps from EBM. As needed, may meet with physician groups and/or hospital personnel.
With operational leadership, monitors site-specific operations dashboard data, identifying opportunities and assisting in the development of appropriate action plans.
Participates in national forums, sharing ideas on best practices with other medical directors and clinical leaders from other UCS sites. As need and opportunity present, participates in national committees and/or the design/redesign and development of programs.
Works in close collaboration with site nursing leadership to provide strong leadership to staff. Supports and champions operational change.
As needed, participates in other utilization management activities such as pre-certification review, appeals and grievance adjudication, etc.
Licensed physician; Board Certified in ABMS/ABOMS specialty
5+ years clinical practice experience
Supervisory skills, including clinical mentoring and coaching expertise Excellent presentation skills for both clinical and non-clinical audiences
Excellent interpersonal communication skills (telephonic and face to face)
The ability to establish rapport with physicians in peer-to-peer communications in frequent daily calls to physicians and facilities regarding perceived gaps in EBM and problem solving to close those gaps
Knowledge of managed care industry
Data analysis and interpretation experience and skills
Strong belief in EBM philosophy
Creative problem solving skills; training in Six Sigma methodology preferred
Strong team player with team building skills
Comfortable with change, and able to lead others through it Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.SMDiversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
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