Texas Health Resources Senior Director Physician Utilization Management-Southwestern Health Resources in Dallas, Texas
Please note: Southwestern Health Resources Clinically Integrated Network (SWHR CIN) is an affiliated company of Texas Health and UT Southwestern. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health or UT Southwestern employee.
Southwestern Health Resources Clinically Integrated Network is hiring for a Senior Director Physician Utilization Management. The Senior Medical Director will act as the primary utilization management physician resource, within the delegated population health/utilization management function in order to keep patients safe, and improve the quality, fraud, waste and abuse. The Senior Medical Director will assess areas within Medical Management (MM) for the purpose of SWHR commercial and Medicare Advantage (MA) contracts that are appropriate for performing timely physician level reviews for medical necessity determinations, quality evaluation, and other utilization management evaluations. Utilization reviews will be based on evidence based guidelines and resources to return the maximum clinical benefit while improving quality of healthcare services delivered, and to the benefit of the member, physician, and SWHR. This position will work in a dyad partnership with the leadership of Utilization Management and Care Management, and will report directly to the Physician Executive and COO within SWHR.
Salary range is Min. $235,539/year to Max. $349,024/year – based on relevant experience
• Full time, day shift
Functional Role and Responsibilities:
Reviews and decides UM cases, ensuring that all requests for services and resources meet medical necessity criteria, and are medically prudent following decision hierarchy, evidence based appropriate use criteria and peer-reviewed guidelines.
Participates in peer to peer discussions with physicians requesting pre-certifications/ authorizations or other medical necessity determinations.
Leverage the utilization management program detail, Health Plan information, and other evidence based tools to provide individualized analysis to providers and facilities and suggest program development or modification within medical management to improve member outcomes.
Will work closely with the VP of Compliance, Senior Directors of Care Management (CM) and Utilization Management (UM), CM/UM staff, and leaders to mandatorily hold the MA programs within strict adherence to CMS regulations and compliance mandates and guidelines. Will assist in maintaining integrity and sustainment of internal and external audits of operations.
Work collaboratively and strategically with the Senior Director of Utilization Management to align the physician driven role of UM in Medicare Advantage with those of the MM operational staff. This work should provide alignment between the operational arms of the physicians and clinical/non-clinical staff.
Collaborates with internal and external entities to improve accessibility standards and quality practice standards to reduce medical costs across the service delivery system. (Inpatient, emergency departments, urgent care services and practitioner office settings).
Work to help maintain a high level of service and effective relationships with the UM Department staff, physicians, hospitals, post-acute and social services, agencies and medical service companies.
Participates in setting policies and procedures for the MM departments and assists in ensuring that Medical Management Program policies and procedures meet regulatory requirements.
Maintains relationships with key leaders of Care N Care and other full risk/MA payers as directed.
Accountable for the overall quality and cost efficiency of Medicare Advantage clinical physician review programs and processes in concert with the leadership of Care Management and Disease Management.
Accountable for compliance with the policies and procedures of SWHR, the standards of accrediting bodies and the regulations of state and local governing agencies.
Evaluates, in conjunction with the Senior Director of UM and other leaders, external review organizations with which SWHR may wish to contract for suitability in matching SWHR compliance rules and overall goals.
Help create strategy alignment between physicians UM reviewers, Care Management and Post-Acute arms of SWHR in order to ensure that, as UM reviews may mandate more appropriate cost of care, that we approach the member from a patient centric viewpoint. Work toward seamless handoffs from utilization review to transitions of care and care management.
Provide leadership and program development to identify RAF and HEDIS Quality capture opportunities including providing assistance in development of processes for cross-divisional communication of these opportunities.
Provide leadership, education and program development for identifying SREs, never events and potential quality concerns as well as assistance in developing processes for communication to appropriate entities.
Ensure concurrent care extended length of stay reviews are occurring with appropriate identification of cases where SWHR intervention can result in streamlined transition through levels of care for complex patients.
Assist in identifying inpatient stays that need to be reported to reinsurer.
Set value thresholds and perform ongoing ROI assessment on internal contracted, external contracted and IRO reviews.
Intermittent, scheduled weekend call coverage for EXP/near TAT reviews to meet regulatory compliance deadlines.
Leadership Role and Responsibilities:
Responsible and accountable for the oversight of assigned UM Medical Directors and midlevel practitioners. Expectation to create medical director policies and procedures in line with regulatory and compliance guidelines and operational requirements for an effective MA delegated MM function with oversight and accountability of these physician functions.
Accountable to creating a work environment for the UM medical directors and contracted physicians to promote success of each individual physician and therefore the payer contract, providers, SWHR, and member.
Responsible for allocating work load of physician level medical reviews among the available internal employed, contracted internal, and external UM physician reviewers.
Responsible for training and periodic evaluation of internally employed and contracted physician reviewers to ensure that they meet SWHR standards for productivity and quality, and all CMS compliance and payer standards.
Responsible for development of inter-reviewer reliability and compliance standards for the MA contracts among all physician reviewers, education programs to ensure the reviewers meet the standards, and evaluating compliance regularly with these standards.
Evaluates performance of employed and contracted physician reviewers in their peer to peer discussions with physicians requesting pre-certifications/ authorizations or other medical necessity determinations.
The ideal candidate will possess the following qualifications
M.D. or D.O. required
Master's Degree in Healthcare Administration, Public Health or Business Administration preferred
5 years general medical clinic practicing physician and 2 years utilization management experience including Medicare Advantage medical review, peer to peer, and physician/ facility liaison functions required.
Licenses and Certifications
MD - Medical Doctor State of Texas or DO - Doctor of Osteopathic Medicine State of Texas required upon hire. Or, the ability to obtain Texas Medical license within 6 months of hire is required.
American Board of Medical Specialty Certification in respective area required upon hire
Strong analytical and organizational skills.
Knowledge of specific regulatory and managed care requirements.
Knowledge of Medicare, Medicaid, and Commercial Coverage Criteria.
Employment opportunities are only reflective of wholly owned Texas Health Resources entities.
We are an Equal Opportunity Employer and do not discriminate against any employees or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.