Utilization Review Manager Jobs in New Port Richey, FL

The High-Risk Program Medical Director (HR-MD) oversees the High-Risk program from a clinical standpoint for the most vulnerable, highest risk Level 4(a) and Level 4(b) patients for Healthcare group. These Level 4(a) and 4(b) patients represent patients with the greatest number of co-morbidities, polypharmacy and Social Determinant of Health (SDOH) factors that lead to the highest levels of Burden of Illness. A significant portion of this population may be indigent, have behavioral health and pain management issues

The HR-MD will initially oversee six teams (one team per Area) consisting of a High-Risk ARNP (HR-NP) and a Clinical Social Worker (HR-CSW) and will be expected to manage, mentor, and guide these teams as well as deliver primary, urgent and acute medical care to the assigned population of Level 4(a) and 4(b) patients. A successful candidate will collaborate with various clinicians along with administrative/operational team(s) to deliver exceptional clinical, operational outcomes to group patients and their families. The HR_MD will be a Medical group Ambassador responsible for working with community physicians, hospitals, and other medical facilities including SNF's, ALFs, urgent care facilities as well as Health Plan clinical and administrative leaders. The HR-MD will be part of the Medical Executive Committee (MEC) at MyCare Medical and will be expected to collaborate with the Senior Medical Directors (SMDs) to provide clinical leadership on multiple topics at Medical Group.

II. ESSENTIAL FUNCTIONS:

• Leads clinical performance expectations that support the goals of consistent clinical performance and practice standards for the High-Risk Program to ensure superior clinical outcomes and unparalleled patient experience for those patients.
• Provides recommendations in the development and/or revision of protocols and procedures pertinent to the treatment of High-Risk patients.
• Works with the Medical Executive Committee, medical staff, and Board of Directors to improve the functionality and effectiveness of all practices in taking care of highly vulnerable patients and the company as a whole.
• Partners with medical staff and central office management teams, facilitating teamwork and shared goals. Represents medical staff viewpoints to management and relays management viewpoints to medical staff by establishing and maintaining mutually beneficial relationships between Medical leadership and community and/or employed physicians.
• Provides clinical support and consultation regarding cost-effective clinical resource management by sharing metrics and recommendations regarding how to reduce the variable cost per case while maintaining and enhancing clinical effectiveness.
• Creates a data-driven environment of quality and cost improvement and develops systems to review utilization of resources and objectively measure outcomes of care in the inpatient and outpatient settings.
• Serves as a direct liaison between Group-affiliated physicians and facility/corporate clinical services functions (care management team, mid-level practitioners in clinics etc.)
• Serves as a resource and consultant to the Vice President of Field Operations, Vice President Clinical Operations and other members of the Executive Team in recruitment, clinical program development, and overall group strategy.
• Provides medical director services to facility-level physician credentialing, business development, and provider relations in contracting issues.
• Provides medical consultation on contracting, pricing, and analysis of managed care issues. Offers clinical support case management, and utilization review/management.
• Consults with facility-level staff regarding delegated utilization management and disease management operations under managed care contracts. Meets all regulatory/contractual/accreditation requirements associated with these functions.
• Attends corporate, group, area and national meetings sponsored by group to train and support quality improvement, risk management, patient safety, case management, and physician relations activities. Quality/Evidence-Based Practice/Patient Safety
• Promotes consistent, positive patient interactions that advance the agenda of unparalleled patient service.
• Provides clinical support and guidance in the development and deployment of all quality initiatives designed to increase the practice of evidence-based medicine within facilities. Utilizes outcomes management techniques to monitor and improve care, quality, and safety. Demonstrates commitment and dedication to communicating the importance and precepts of evidence-based practice.
• Serves as a spokesperson for evidence-based clinical practice, patient safety, and clinical loss prevention to facility leadership and clinicians.
• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) required
• Current and valid state medical license required
• 7+ years experience managing an interdisciplinary team of clinical personnel (APRNS, CSWs, Mas, other MDs etc.)
• 15+ years minimum experience as a community physician providing geriatric care to patients with highly complex medical conditions and multiple co-morbidities
• Geriatric certified preferred
• Palliative care certified/focus preferred
• Basic Life Support (BLS) certified
• Have a valid drivers license, have access to a car and willingness to drive to patient homes/patient location as well as an active auto insurance policy
• Proficient in EHR medical documentation
• Familiarity with HCC coding and utilization management preferred
• Strong computer skills, including Word, Excel, and Powerpoint
• Strong verbal, written, presentation, and interpersonal communication skills
• Excellent bedside manner and time management skill
• Demonstrated ability to work effectively independently and as part of a team in collaborative settings required
• Demonstrated ability to provide leadership to staff and to build the trust and respect of patients, staff, colleagues, and external contacts
• Must possess strong clinical skills in the management of seniors with complex medical needs throughout all environments of care
• Strong leadership and communication skills, the ability to build relationships with external organizations, and interest in information technology applications in medical settings
• Ability to effectively work across multiple markets and teams to optimize the performance of local leaders and their teams
• Excellent problem-solving skills, including creativity, resourcefulness, timeliness, and technical knowledge related to analyzing and resolving medical/administrative problems
• Good analytical skills and the ability to manage for result
• Excellent medical skills with proven positive outcomes
• Conflict management and resolution skills, and ideally, experience of population risk management or complex chronic disease care management

IV. PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit. The employee is required to stand and talk or hear. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision.

V. WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually quiet.