Utilization management (UM) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan, sometimes called “utilization review in order to ensure the judicious use of the facility’s resources and high-quality care.””
Utilization review contains three types of assessments: prospective, concurrent, and retrospective.
A prospective review assesses the need for healthcare services before the service is performed. Providers must often submit prior authorizations to health plans under this utilization review process to ensure the most appropriate services are being rendered.
For concurrent reviews, services are reviewed during the hospitalization or care episode. The review encompasses case management activities, such as care coordination, discharge planning, and care transitioning, and primarily focuses on the appropriateness of length of stay and initial discharge plans.
Retrospective review is the process of assessing appropriateness of procedures, settings, and timings after the services have been rendered. Hospitals typically have a specialized nurse or claims expert perform retrospective reviews to ensure claim submissions contain complete, correct billing codes for services provided.
Utilization management and review can prevent hospitals from receiving retrospective claim denials and being forced to relinquish money already received.
Implementing a strong utilization management program to verify that patients are receiving the right care at the right time will ensure that hospitals are delivering appropriate, cost-efficient care.
Below are some of the descriptions mentioned in the actual UM jobs that were posted online.
Duties and Responsibilities of Medical Directors working for Commercial Insurers:
Responds to requests for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management department in a timely fashion.
Provides consultation to attendings, nurses, and case management staff regarding complex clinical issues and advises on justification required for continued stay, medical necessity and utilization management
Maintains accountability for achieving case management outcomes and fulfills the obligations and responsibilities of the role to support the medical staff in the clinical progression of patient care.
Demonstrates positive outcomes through interventions with attending or consulting physicians that delay care and affect the length of stay or avoidable delays, etc.
Describes ways to provide improved health record documentation that specifically affect ICD code assignment capture of severity, acuity, risk of mortality, and DRG assignment.
Participates in ongoing training and education related to the Physician Advisor role and responsibilities including topics related to Utilization Management, Care Management and other related areas as requested.
Meets production standards within established time requirements. Work product and performance meets quality standards.
Achieve performance goals as outlined in employment agreement.
Preferred Qualifications of Medical Directors working for Commercial Insurers:
MD or DO degree with strong clinical knowledge
1-3+ years of experience in a hospital-based practice setting
Board Certified / Eligible
Active unrestricted medical license in at least one state within the United States
Required specialization in Adult Internal Medicine, Emergency Medicine, Hospitalist, Nephrology, or Infectious Disease. Strong clinical knowledge base across multiple areas.
Recent relevant physician advisor experience.
Basic knowledge of with McKesson InterQual criteria and Milliman Care Guidelines (MCG).
Physician Advisor Sub-Specialty Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) preferred.
Member of the American College of Physician Advisors (ACPA) preferred
Possess a working knowledge of (Hospital) organization & case management operations and administrative standards and policies.
Skills of Medical Directors working for Commercial Insurers:
Team Player.
Experience with EMRs.
High ethical standards. Maintains confidentiality.
Excellent analytical and deductive reasoning skills.
Good judgement and problem-solving skills. Attention to detail.
Professional and effective communication skills. Written and verbal fluency in English. Must be professional, organized and possess persuasive writing and speaking skills.
Strong organizational skills.
Good conflict resolution skills.
Proficient in the use of Microsoft Office products such as Outlook, Excel, Word & PowerPoint.
Home office that is HIPAA compliant.
Demonstrates ability to drive results and produce outcomes.
Diplomatic, Negotiation and peace keeping skills.
Physical Requirements of Medical Directors working for Commercial Insurers:
Physical requirements include, but not limited to, sitting for extended periods of time and function in an environment with constant interruptions is require with repetitive movement of hands/fingers (i.e., typing and/or writing), and ability to talk and hear.
What the commercial insurances Offer for Medical Directors working for Commercial Insurers:
Comprehensive training and education program.
Opportunities for career growth within the organization.
Salary plus bonus opportunities.
Comprehensive Medical, Dental, Vision & RX Coverage.
Paid Time Off, Volunteer Time & Holidays.
401K with Company Match.
Company-Paid Life Insurance, Short-Term Disability & Long-Term Disability.
Tuition Reimbursement.
Parental Leave.
Life insurance.
Allowance for CME and/or licensure renewal.
Also read:
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