Career Center

• Daily census review and length of stay (LOS) rounding with case managers to identify cases with discharge barriers, provides intervention and coordination of discharge plans for appropriate utilization. Utilizes afternoon rounds for priority cases, failed discharges to review treatment and discharge plans.
• Leads status determination by reviewing level of care and length of stay management on admission.
• Daily evaluation and review of one day stays and observation patients.
• Assists with the denial management process through review of observation and one day cases, makes suggestions regarding resource and service management and assists staff with the clinical review of patients to assure professionally recognized standards of quality care are met
• Real time intervention when practice/behaviors create disparity between practice standards, LOS, intensity of service, severity of illness, patient and family rights,
• Team work or other issues regarding the stewardship of resources for individual patient
• Provides feedback and education to attending and consulting physicians regarding level of care, length of stay, and quality issues. Seeks additional clinical information from the attending and consulting physicians when clinical documentation does not support admission status. Recommends and requests additional, more complete, medical record documentation. Recommends next steps in coordination of care and evidence-based medicine indicators.
• Reviews cases that indicate a need for issuance of a hospital notice of non-coverage. Discusses the case with the attending physician and if additional clinical information is not available, discusses the process for issuance and appeal to the physician.
• Documents patient care reviews, decisions, and other pertinent information per hospital policy in EPIC when required (Clinical Determination Status for all patients: Observations, Inpatient, and Outpatients based on documented reasons for hospitalization in the medical record). Understands and uses Milliman Care Guidelines and other appropriate criteria. Documents response to case management referrals in EPIC.
• Leads review of multidisciplinary and weekly long stay patients, in conjunction with the Director of Case Management, to facilitate the use of the most appropriate level of care and LOS.
• Acts as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate. Facilitates, mentors, and educates other physicians regarding payer and compliance requirements.
• Peer to Peer educator to physician colleagues regarding impact of individual cases on overall health and function of hospital. Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, and alternate levels of care, community resources, and end of life care. Works with physicians to facilitate referrals to the continuum of care.
• With the CMO, identifies reports necessary for focused interventions
• Leads the Inova UM system committee for operating unit.
• Serves on the medical staff committee that oversees utilization management for operating unit.
• Notifies the case manager of any conflict of interest in reviewing a particular patient record. Assists with identifying a physician to review such record.

• Participates in the peer review process; makes suggestions on ways to improve this process.
• Evaluation of the hospital utilization management program.
• Maintains current knowledge of federal, state, and payer regulatory and contract requirements.
• Attends continuing education sessions pertaining to utilization and quality management.
• Meets with corporate and hospital case management staff as needed.

Education: Graduate of an accredited medical school. Additional education in quality and utilization management through continuing medical education programs and self-study.

Experience: Minimum of 5 years recent experience in clinical practice. Utilization management experience as a member of the UM oversight committee or past physician advisor experience preferred.

Certificate/License: Current Commonwealth of Virginia license to practice medicine and eligibility for active membership on the hospital medical staff.

Physical Demands: Ability to travel to various hospital and Inova locations, including patient care areas, conference facilities, Inova Health System Office, other sites as requested.

Working Environment: Office and patient care areas.

Supervision Received: The Operating Unit CMO for clinical issues and VP of

Case Management for system administrative issues.