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Inpatient Case Management Medical Director - Northeastern or Southeastern US - Virtual

UnitedHealth Group

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Inpatient Case Management Medical Director - Northeastern or Southeastern US - Virtual(Job Number:721555)

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.

• 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.

Job Clinical Analysis & Consulting
Primary Location US-Rhode Island
Other Location US-NY-New York, US-FL-Tampa, US-NC-Charlotte, US-GA-Atlanta, US-MA-Boston
Organization Inpatient Care Mgmt - MD
Schedule Full-time
Number of Openings 1
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UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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