Summary:Ensures documentation, data capture and opportunities for utilization are compliant, accurate and consistent.Responsibilities:Makes decisions on referred individual patient cases regarding: Pre-admission, authorization, Medical necessity and services/setting, transfers, appropriateness of admission, and continued stay. Conducts peer to peer discussions with health plans when required.Works in collaboration with the Medical Director of Centralized UR/HIM, utilization committees and medical staff to maintain and improve utilization and documentation efforts.Performs regular, follow-up and focused chart audits/reviews (concurrent and retrospective) for the purpose of assessing the accuracy of clinical documentation and utilization. Ability to work weekends and holidays as needed.Serves as a resource to the medical staff for Utilization Review activities. Educates and communicates to the Medical staff the benefits/need for utilization review and documentation.Competencies:Education and Certification Requirements:Medical Doctor (Required)Medical Doctor License (ME LICENSE) - State of Florida (FL), Osteopathic Physician License (OS LICENSE) - State of Florida (FL)Additional Job Information:Complexity of Work: Requires critical thinking skills, effective communication, decisive judgment and the ability to work with minimal supervision. The incumbent must be able to work in a stressful environment and take appropriate action when required.Required Work Experience: Minimum of 1 year of work experience in a clinical settingOther Information: Prior experience in Utilization Management with hospital system or health system preferredAdditional Education Info: Graduate of a medical school approved by the Council on Medical Education of the American Medical Association.About Memorial Healthcare System
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