Medical Director Physician Advisor UM

AdventHealth; United States; Presencial; USD 250 000 - 376 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Medical, Dental, Vision Insurance

Life Insurance

Disability Insurance

Paid Time Off from Day One

403-B Retirement Plan

Parental Leave

Career Development

Whole Person Well-being Resources

Mental Health Resources and Support

Pet Benefits

Resumo da oferta

AdventHealth is Seeking a senior clinical liaison to support Utilization Management and Care Management. This role educates medical staff on UM/CM best practices, builds relationships with physicians and payors, and guides staff on authorizations, denials, and medical necessity decisions.

The position coordinates with facilities, ACO programs, and regulatory bodies to promote high-quality, cost-effective patient care and supports ongoing quality initiatives across inpatient and outpatient

Qualificações

• Doctorate is required.
• Master's degree is preferred.
• Strong organizational and analytical skills are required.
• Excellent communication skills are required.
• Understanding of Microsoft Office and related software platforms.
• Experience in a matrix-management environment is expected.
• Demonstrated ability to provide expert medical advice.
• Payor experience in operations and physician group models is preferred.

Responsabilidades

• Provide clinical support and validation for UM and CM.
• Educate Medical Staff on UM/CM best practices and guidelines.
• Build relationships with physicians and UM/CM stakeholders.
• Advise on clinical questions and provider interactions.
• Serve as liaison between facilities, payors, physicians, and ACO programs.
• Guide UM staff on authorizations, concurrent review, denials and medical necessity criteria.
• Participate in peer-to-peer discussions with payors to resolve cases.
• Review denials data and KPIs for utilization improvement.
• Collaborate with CM, CDI, Quality, and Patient Safety teams.

Conhecimentos

Organization

Analytical skills

Communication skills

Microsoft Office

Matrix-management

Policy interpretation

Clinical advisory

Physician collaboration

Payor experience

Physician group model

Formação académica

Doctorate

Master's

Ferramentas

Microsoft Office

Descrição da oferta de emprego

Company Promise

Our promise to you: Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Job Description Summary

Supports Utilization Management (UM) and Care Management (CM) by serving as a liaison between these teams, medical staff, and payors. They educate and advise UM, CM, Managed Care, Revenue Cycle, and medical staff while helping improve clinical documentation, patient safety, and quality outcomes. The role includes clinical review of utilization, claims management, and quality assurance for inpatient, outpatient/observation, and referral services. Also acts as a key clinical and business resource for clinicians, payors, and regulatory agencies to promote high-quality, cost-effective patient care.

Job Description

Provides clinical support and validation for Utilization Management (UM) and Care Management (CM). Educates and serves as a resource to Medical Staff on UM/CM best practices and clinical guidelines. Builds effective relationships with physicians and UM/CM stakeholders. Advises UM/CM on approaches to clinical questions and provider interactions. Serves as liaison between facilities, payors, physicians, and ACO programs. Guides UM staff on authorizations, concurrent review, denials, and medical necessity criteria. Performs secondary inpatient review escalations and evaluates utilization patterns. Supports formulation of clinical arguments for level-of-care determinations. Coordinates concurrent and retrospective denial management and assists with appeals. Develops and maintains relationships with payor Medical Directors to improve claims outcomes. Conducts peer-to-peer discussions with payors to resolve cases and improve collaboration. Reviews denials data, trends, and KPIs to identify utilization and process improvement opportunities. Collaborates regularly with CM, CDI, Quality, and Patient Safety teams to improve outcomes. Participates in Medical Staff committees and provides input on clinical pathways, guidelines, and policies. Performs other duties as assigned.

Knowledge, Skills, and Abilities

• Strong organization skills with attention to detail [Required]
• Excellent analytical and problem-solving skills [Required]
• Effective oral and written communication skills, with the ability to articulate complex information in understandable terms to all levels of staff [Required]
• Understanding of Microsoft Office Products and other appropriate software platforms [Required]
• Ability to work in a matrix-management environment to achieve organizational goals [Required]
• Ability to translate ethical and legal requirements into practical and sustainable policies, balancing the needs of the business and the interest of patients and member physicians alike [Required]
• Demonstrated ability to provide expert medical advice [Required]
• Successful history as a practicing physician [Required]
• Demonstrated ability to build and sustain relationships in the medical community and a corporate environment [Required]
• Payor experience in operations [Required]
• Experience in a physician group model [Required]
• Knowledge of change management principles, methodologies, and tools [Preferred]
• Direct involvement with supporting the development of a Utilization Management and Care Management departments [Preferred]
• Prior experience with third party payors [Preferred]

Education

• Doctorate [Required]
• Master's [Preferred]

Pay Range

Pay Range: $250,348.8k - $375,523.2k

Benefits and Perks

All the benefits and perks you need for you and your family:

• Medical, Dental, Vision Insurance
• Life Insurance
• Disability Insurance
• Paid Time Off from Day One
• 403-B Retirement Plan
• 4 Weeks 100% Paid Parental Leave
• Career Development
• Whole Person Well-being Resources
• Mental Health Resources and Support
• Pet Benefits

Schedule

• Schedule: Full time
• Shift: Day (United States of America)

Job Location

Address: 900 HOPE WAY City: ALTAMONTE SPRINGS State: Florida Postal Code: 32714

Background Screening Requirement

Background Screening Requirement (Florida Law) Certain positions are subject to Florida Level 2 background screening, including fingerprinting, as required by state law. Applicants may review general information about Florida's background screening requirements at the Florida Care Provider Background Screening Clearinghouse: https://info.flclearinghouse.com/

Equal Opportunity Statement

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Company Mission

Every day, our fellow team members show up to work, unified by one shared mission: Extending the Healing Ministry of Jesus Christ. As a faith-based health care organization, our story is one of hope as we strive to heal and restore the body, mind and spirit. Though our facilities are spread across the country, this unwavering belief binds us together. Across every office, exam and patient room, we're committed to providing individualized, holistic care. This is our Christian mission, and it inspires us to help make communities healthier and happier.