As the Medical Director - Post Acute Care you will provide clinical oversight for 1 or more CareCentrix markets including Utilization of Post-Acute Care (PAC) facilities, medically appropriate steerage to home, coordination of discharges and post discharge follow up to prevent readmissions. A key part of the role is to work strategically with UM leaders and market engagement director to overcome facility barriers to discharge. Peer-to-Peer conversations with hospital physicians as needed to impact admissions to PAC facilities and PAC length of stay. In this role, the Medical Director will perform medical necessity reviews utilizing industry standard criteria, as well as client specific clinical criteria, for PAC facilities: Skilled Nursing Facility (SNF), Long Term Acute Care Hospital (LTCH) and Inpatient Rehabilitation Facility (IRF). The Medical Director will also be responsible to support the nurse coach readmission prevention program for 90 days post discharge.
In this role, you will:
Conduct medical necessity reviews adhering to regulatory and compliance turnaround times on cases that may not meet clinical criteria, and issues adverse determinations as needed.
Provide guidance to licensed and non-licensed associates on clinical issues and case reviews related to authorization requests and clinical guidelines criteria.
Provide education to UM team to support Post Acute Care needs, discharge planning, length of stay management and readmission reduction.
Complete peer-to-peer discussions as indicated at the time of PAC facility admissions when medical necessity criteria are not met, to facilitate proactive discharge planning or when facility stay is no longer medically indicated.
Participates in CareCentrix Care Coordination, Utilization Management, Quality Improvement and clinical education activities, as requested.
Utilize clinical integrity in all determinations and interactions with internal and external partners.
Collaborate with Health Plan clinical leadership as requested.
Interface with key positions within CareCentrix including reporting to the Senior Medical Director and interacting with the Chief Medical Officer and executive team members.
Collaborate with Market Engagement Directors and facility provider Joint Operations Committee activities as requested/needed Successfully completes and passes Inter-rater reliability testing and random case audits.
Achieves Service Level Agreement (SLA) metrics and performance guarantees as required by health plan clients.
Some weekend work required
You should get in touch if you have:
MD or DO with an active and unencumbered medical license. Must have active ABIM or ABMS specialty board certification(s).
Minimum of 5 years’ experience in an area of relevant clinical practice , and prefer at least 3 years’ experience with supporting utilization management reviews, managed care programs or care delivery networks
Expertise in the Post-Acute Care field, including current knowledge on best practices, as well as a general knowledge of requirements of regulatory and accreditation standards for payers and health care providers
Expertise in Medicaid health plan or UM is preferred
Excellent written and verbal communication skills.
Convey a strong professional image, exhibit interest quality improvement and project a positive attitude toward all assigned work.
Adheres to and participates in Company's mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.
What we offer
Full range of benefits including Health, Dental and Vision with HSA Employer Contributions and Dependent Care FSA Employer Match.
Generous PTO, 401K Savings Plan, Paid Parental Leave, free on-demand Virtual Fitness Training and more.
Advancement opportunities, professional skills training, and tuition Reimbursement
Great culture with a sense of community.
We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.
CareCentrix empowers health at home through whole-person care coordination and value-based benefit management. Our home-centered approach starts with the members we support, leveraging data and insights to deliver the right care at the right time from hospital to home.
We connect the last mile of care, as a single platform, for health plans and health systems to improve outcomes, lower total cost of care, deliver member and provider satisfaction, enhance Stars and HEDIS® measures1, and guarantee savings.
CareCentrix supports Medicare Advantage, Medicaid, commercial populations. Our solutions include Post Acute Care: Site Optimization, Readmissions Management, Home Health, DME, Home Infusion, Home Sleep & Respiratory, and Serious Illness Care at Home.
Since 1975, the American Association for Physician Leadership has helped physicians develop their leadership skills through education, career development, thought leadership and community building.
Now more than ever, physicians are leaders in their organizations and communities. The American Association for Physician Leadership® maximizes and supports physician leadership through education, community, and influence.