WellSpan Health

General Summary

Provides direct supervision of case management and utilization review activities performed by the WellSpan Case Management staff.

Duties and Responsibilities

• Renders utilization management determination in accordance with State and Federal regulations and coordinates resolution between the treating physician and health plan medical management services.
• Facilitates WellSpan’s partnership with health plan and payers medical management leadership for optimum population management in accordance with contractual agreements.
• Is a member of and attends the monthly Utilization Review committee, identifies cases for review and contributes to setting the agenda.
• Provides leadership support for Population Health Strategies including ACO development, WellSpan Provider Network operations, Medical Home/ Neighborhood development and the Bridges to Health programs at the request of the Medical Director.
• May serve as a liaison between physician advisors in the designated geographic area and the Medical Director of Corp. Case Management
• Attends CM RN morning report huddle as needed to identify/discuss problem cases, share and reinforce policies and provide clinical education.
• Provides immediate clinical consultative services face to face or by phone to trouble shoot urgent issues with the CM nurses.
• Reviews cases for determination of level of care and verify need for peer to peer review—discuss with the CM nurse and/or attending physician as needed and then document activities.
• Performs other peer to peer calls as needed.
• Identifies and documents failed peer to peer cases for need of retrospective external appeal—and funnel those cases to the Supervisor of Utilization Management for expedition.
• Reviews cases forwarded from CM nurses and the CMRN in charge of readmission review for concurrent quality review, determine the level of concern and funnel cases to the appropriate parties for action plans (according to the Readmission Quality Review process).
• Identifies opportunities for process and content improvement within the Case Management workflow, patient care and discharge planning.
• Meets periodically with the CM leadership team to help drive performance improvement.
• Generate letters for appeal purposes if as needed (this is currently the role of the retrospective part time PA primary activity).
• Identifies super utilizers and coordinate/document care plans and administrative alerts. Huddle with outpatient primary care providers as needed. Assist with Bridges to Health referrals and cases as needed.
• Provides Physician Advisor support to all WellSpan entities as needed and at the direction of the Medical Director of Corp. Case Management

Common Expectations:

• Fully documents review activities according to outlined CM policy and denial process.
• Familiarity with InterQual, Milliman and other nationally accepted guideline.
• Provides daytime physician advisor coverage with availability in person or by phone 8-5p during business days unless taking PTO.
• Follows established policies and procedures of WellSpan Case Management.
• Handles patient identifying information in a secure fashion within communications.
• Acts in a professional manner and uses a “Just Culture” approach to his/her interactions with the hospital and medical staff.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Participates in weekend and holiday coverage schedule.
• Prepares and presents utilization data analysis as required.
• Develops and initiates educational programs regarding utilization management principles.
• Assists with special projects as needed.
• Attends meetings and huddles as required.

Required for All Jobs:

• Performs other related duties as identified.
• WellSpan Health has adopted and implemented a compliance program to support WellSpan's values and standards for professionalism, integrity, and ethics. Expected to support and meet the values and standards of the organization and the performance expectations of the job, the department, and the compliance program.
• WellSpan Health has adopted and implemented a privacy program to safeguard the patient information and the business and operational information of the organization. Expected to support and meet the values and standards of the organization to safeguard patient and business/operational information.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.

Qualifications

Minimum Education:

• Doctor of Medicine (MD) Required or
• Doctor of Osteopathic Medicine (DO) Required

Work Experience:

• 5 years Clinical experience in hospital medicine. Required
• Less than 1 year Experience with peer review and/or case management. Family Medicine, Internal Medicine, or General Surgery as preferred background specialties. Preferred

Licenses:

• Licensed Medical Physician and Surgeon Upon Hire Required or
• Licensed Doctor of Osteopathic Medicine Upon Hire Required

Knowledge, Skills, and Abilities:

• Extensive knowledge of the EMR functionality.

WellSpan’s vision is to reimagine healthcare through the delivery of comprehensive, equitable health and wellness solutions throughout our continuum of care. As an integrated delivery system focused on leading in value-based care, we encompass nearly 1,900 employed providers, 220 locations, eight award-winning hospitals, home care and a behavioral health organization serving South Central Pennsylvania and northern Maryland. With a team more than 20,000 strong, WellSpan experts provide a range of services, from wellness and employer services solutions to advanced care for complex medical and behavioral conditions. Our clinically integrated network of 2,600 aligned physicians and advanced practice providers are dedicated to providing the highest quality and safety, inspiring our patients and communities to be their healthiest.