Medical Management Director directs and oversees the operations and strategic planning of the organization's medical management initiatives and programs. Establishes case management, utilization review, quality and outcome management, and community education programs to provide high quality, cost effective health care services. Being a Medical Management Director develops and implements clinical guidelines for care designed to improve outcomes while managing costs. Requires a bachelor's degree. Additionally, Medical Management Director typically reports to top management. The Medical Management Director typically manages through subordinate managers and professionals in larger groups of moderate complexity. Provides input to strategic decisions that affect the functional area of responsibility. May give input into developing the budget. Capable of resolving escalated issues arising from operations and requiring coordination with other departments. To be a Medical Management Director typically requires 3+ years of managerial experience. (Copyright 2024 Salary.com)
Duties and Responsibilities
• Oversight of the Facility’s Case Management team to ensure compliance with standards of practice and other regulatory requirements related to care management and utilization review.
• Develop and foster effective collaboration between Case Management Departments, Medical Staff, corporate and facility leaders to ensure an integrated approach to providing care while fulfilling the hospital's goals and objectives.
• Display an ability to work effectively within the health system's decision making and organizational structures.
• Work closely with providers as well as internal and external physician advisors for utilization review and management activities
• Coordinate all UM Committee activities to ensure compliance with meeting frequency and documentation of activity and outcomes
• Work collaboratively with Revenue Cycle teams and participates in task force meetings related to medical necessity audits and denials.
• Participate in appeals processes and work collaboratively with vendors to ensure the effectiveness and timeliness of appeals
• Analyze length of stay and readmissions data and incorporate measures with Operations team members, Corporate Case Management Directors and other facility leaders to ensure goals are met
• Introduce evidenced based practices geared to improve case management and transitions
• Conduct regular staff meetings to review pertinent Federal and State regulatory requirements, emerging internal and external trends, and provide general training for staff
II. Position Requirements:
A. Licensure/Certification/Registration:
Applicants with the following licensure may be considered: Oklahoma RN
B. Education: BSN preferred, Registered nurse is required. Certification in Case Management or Utilization Review is preferred
• Demonstrated leadership and complex organizational management skills • Excellent management, problem solving, team building & organizational skills • Familiarity with Federal & State regulations related to case management discharge planning. • Knowledge of integrated discharge planning practices and resources available to patients • Demonstrated knowledge of RACs, MACs and the Medicare appeals process • Ability to work with Administration, Physicians, and staff in multiple settings • Ability to compile reports and interpret data • Ability to prepare and administer presentations Ability to interpret and apply InterQual criteria |
Experience: A minimum of 5 years experience in case management, discharge planning, and/or utilization review in an inpatient acute care setting. Strong clinical background is preferred.