Position Overview: As the Medical Director of Utilization Management, you will play a crucial role in championing best practices and ensuring evidence-based care through effective communication with the medical staff and Care Management team. You will be responsible for improving hospital outcomes by recommending appropriate levels of care for hospitalized patients while ensuring accurate documentation to prevent denials. Your expertise in utilization management, state and federal regulations, denials and appeals processes, and physician documentation will be invaluable in this role.
- Conduct second-level medical necessity reviews for patient cases that do not meet first-level screening criteria or lack the documented length of stay expectations.
- Collaborate with admitting physicians and utilization management to assess medical necessity and appropriateness of admissions, observation status, continued stay, and ancillary services.
- Act as a liaison between the medical staff and Utilization Management, providing consultations, education, and guidance on federal and state utilization and quality regulations.
- Interact with medical review physicians and medical directors of third-party payers, offering clinical opinions regarding patient needs.
- Chair the Utilization Management Committee and the Performance Improvement Committee, identifying inefficiency trends, recommending actions, and reviewing outcomes.
- Stay updated on policies and procedures related to Utilization Management.
- Contribute to activities aimed at improving operational and financial performance, quality, and patient satisfaction.
- Attend meetings as requested by Hospital administration and actively participate in assigned Hospital committees and activities.
- Education/Training: M.D. or D.O. with Board certification by the American Board of Medical Specialties or Bureau of Osteopathic Specialists. Additional education or training in utilization management is preferred. Must be an active member of the medical staff in good standing.
- Certification, Licensure, Registration: Certification in health care quality management with a Medical Director subspecialty (CHCQM-PHYADV) is preferred.
- Experience with utilization management, physician documentation, and EMR (EPIC)
- Knowledge of the denials and appeals process, reimbursement issues relating to medical necessity, quality management, case management, and physician education
- Ability to communicate and present information effectively
Note: The Medical Director of Utilization Management is an active member of the LMC's Process Improvement Committee (PIC) and reports data on utilization management and observation services to the PIC Committee and Utilization Management Committee. The Medical Director is also the chair of the UM Committee that meets bimonthly. Also, performance metrics and additional information will be shared with selected candidates during the interview process to provide a comprehensive understanding
Why Join Our Team: By joining our team as the Medical Director of Utilization Management, you will have the opportunity to lead and collaborate with a dedicated team of healthcare professionals. You will be at the forefront of driving operational and financial performance, improving quality outcomes, and enhancing patient satisfaction. We offer a competitive compensation package, comprehensive benefits, and a supportive work environment that encourages professional growth and development.
About Lexington Medical Center:
Lexington Medical Center is a 607-bed hospital in West Columbia, South Carolina. It anchors a health care network that includes five community medical centers and employs a staff of more than 7,800 health care professionals. The network includes a cardiovascular program recognized by the American College of Cardiology as South Carolina s first HeartCARE Center. The network also has an occupational health center, the largest skilled nursing facility in the Carolinas, an Alzheimer s care center and 70 physician practices. Lexington Medical Center operates one of the busiest Emergency departments in South Carolina, treating nearly 100,000 patients each year. The hospital delivers more than 4,000 babies each year and performs more than 25,000 surgeries.
We've been named Columbia's "Best Place to Have a Baby," "Best Hospital" and one of the "Top 25 Best Hospitals to Work for in the U.S.," honors all made possible by a dedicated, talented team of health care professionals and staff.
We are committed to offering quality, cost-effective benefits for our employees and their families. Competitive Day ONE Benefits:
- Medical, Dental, and Vision Insurance
- Retirement and Savings Plans with No Vesting Period
- 24/7 Live Epic EMR Support from Our On-site Team
- Relocation Assistance and Sign On Bonus
- Annual CME Allowance
- Medical Malpractice Coverage
- Life, Accidental, and Critical Illness Insurance
- Employer Paid Short- and Long-Term Disability (after 90 days)
- Healthcare FSA
- Daycare FSA
- 529 College Savings Plans
- Adoption Assistance
- Dependent Life Insurance
- On-site Child Care Center
- Public Service Loan Forgiveness (PSLF) Employer
- Health Directions Gym Membership
- Employee Discounts and Services
Additionally, all new physicians in the Lexington Medical Center network receive a marketing plan designed to introduce them to patients living in our community and assist the physician with growing a thriving practice.
- Affordable Cost of Living
- Close proximity to beautiful Lake Murray
- Family friendly community, Home to some of the best school districts in the state
- Centrally located, driving distance to 7 major airports
- Annual average temperature is 68 degrees in December
- 1.5 hours from Charleston, 2 hours from Asheville
Lexington Medical Center is located near the capital city of Columbia, South Carolina, home to the University of South Carolina. Enjoy SEC Division I sporting events, top quality entertainment at the Colonial Life Arena and the Koger Center for the Arts, energetic nightlife in the Congaree Vista, or stroll Main Street during the Saturday morning Soda City Market. Its central location, favorable economic environment, cultural diversity, and recreation opportunities make the Columbia area an ideal place to work, live, and play.