Medical Director, Case Management
Company: Memorial Hermann Health System
Posted on: July 22, 2021
At Memorial Hermann, we're about creating exceptional
experiences for both our patients and our employees. Our goal is to
provide opportunities for our diverse employee population that
develop and grow careers in a team-oriented environment focused on
Every employee, at every level, begins their journey at Memorial
Hermann learning about the history of the organization and its
established culture built on trust and integrity. Our employees
drive this culture, and we want you to be a part of it.
The Medical Director, Case Management ('CMMD') will oversee
aggregate length of stay processes, readmissions initiatives,
post-acute transitions, and utilization review of patient bedding
status. The CMMD will review referred and selected cases for
appropriateness of admission, level of care criteria, continuing
stay, length of stay, medically necessary services, and appropriate
post-acute disposition. In addition, the Medical Director will
facilitate communication and problem resolution with attending and
treating physicians through multidisciplinary work and/or direct
physician contact. The Medical Director works collaboratively with
the Director of Case Management and the department staff, including
Case/Care Managers, Social Workers, Referral Coordinators,
Navigators, and Resource Center staff. The position is credentialed
by MHMD and privileged at one or more hospitals. The CMMD must be
able to demonstrate knowledge and skills necessary to provide care
management appropriate to the patient population served. The
Medical Director must demonstrate knowledge of the principles of
growth and development as it relates to the different life
Education: Medical Doctorate (MD) or Doctor of
Osteopathic Medicine (DO) degree from an accredited medical school
required; Additional education and/or experience in the areas of
management, utilization and/or quality preferred
- Licensed to practice as MD or DO in the state of
- Board certification in primary care or medical specialty
area is preferred
Experience / Knowledge / Skills:
- Five (5) years experience in clinical setting
- Current staff privileges at one or more MHHS hospitals
- Ability to work collaboratively to achieve established goals
and exercise independent judgment with minimal supervision or
- Recognition by peers as an outstanding clinician
- Proven capability to communicate and to develop positive
relationships with physician colleagues and non-physician
- Working knowledge of regulatory, payer and utilization
- Demonstrated accuracy and understanding of medical
documentation and coding
- Strong interpersonal, analytical and organizational skills
- Incumbent must demonstrate objectivity, flexibility and tact in
dealing with potentially sensitive medical staff issues, practice
patterns, and clinical resource utilization
- Effective oral and written communication skills
- Demonstrates commitment to the Partners-in-Caring process by
integrating our culture in all internal and external customer
interactions; delivers on our brand promise of "we advance health"
through innovation, accountability, empowerment, collaboration,
compassion and results while ensuring one Memorial Hermann and an
optimal end-to-end health experience.
- Reviews individual cases concurrently and retrospectively,
including denied cases.
- Case reviews may be required independently, in
multidisciplinary round collaborations, and as requested by
- Reviews appropriateness of admission, continuing stay, medical
necessity of services and safe, appropriate post-acute plan.
- Reviews will employ CMS guidance, utilization management
criteria sets, MHHS guidelines, Local and National Coverage
Determinations, and clinical judgment.
- CMMD's will be expected to apply professional judgment and
review patient-specific variables on reasonable and necessary
- Serves as a member of the care management oversight team,
acting as a key physician liaison among hospital medical
staff/practitioners, hospital case management and care
management/health plan partners.
- Communicates with physicians to capture additional pertinent
information for evaluation of medical necessity and appeal letter
- Communicates with attending and treating physicians in order to
resolve issues regarding patient bedding status, length of stay,
appropriateness of services, transitions of care, post-acute
disposition, and resource utilization in collaboration with case
- Supports and participates in local and/or system MHHS
communication initiatives regarding health management.
Compliance and efficiency
- Assists MHHS in delivering the services in an efficient manner
in compliance with applicable legal and accreditation
- Stays current on Medicare and State of Texas rules and
regulations and applicable payer requirements.
- Advocates with staff for timely, efficient, appropriate and
- Advocates for patient health and an integrated, optimal
end-to-end patient/member experience.
- Advocates in a collaborative and team-based fashion through the
chain of command.
Assessment and monitoring
- Monitors the clinical and business aspects of physician
advising and utilization management activities.
- Reviews all routine reports and performance measures and
prepares limited analysis for the purposes of informing leadership,
supporting utilization management committee, and educating
- Makes recommendations to system, regional, department and
campus leadership regarding opportunities for health management
enhancement, appropriate clinical documentation practices,
medically necessary resource utilization, denial avoidance and
length of stay improvement.
Collaboration with leadership
- Work collaboratively with the care and case management
directors on utilization committee preparation, on concerted
approaches to utilization improvements for clinical services, on
complex and outlier cases, and on standardization interdisciplinary
review and collaboration.
- Works to ensure medical staff leadership, CMO(s) and UM
Committee chairs receive timely information and updates on the
efforts of physician advisors.
- The CMMD may serve as Vice Chair or Co-chair of the Utilization
Management Committee, in support of committee leadership and other
medical staff participants.
- Formulates medical necessity and appeal letters with Case
Management, UM Committee leadership and other leadership as
- Reviews medical necessity appeals letters and follows the
- Performance Improvement
- Assists in the development, implementation and carrying out of
performance improvement and quality assessment efforts related to
case management and care management.
- Provides ongoing education and information to medical staff and
care/case management staff regarding best practices, organizational
structures and functions, use of clinical guidelines, appropriate
levels of care, documentation, and relevant new regulation.
- Participates in care coordination pathway development and
workflow innovations through the Clinical Program Committees and
Safety, Standards and Development
- Participates in relevant professional development organizations
as approved by supervisor.
- Ensures safe care to patients, staff and visitors; adheres to
all Memorial Hermann policies, procedures, and standards within
budgetary specifications including time management, supply
management, productivity and quality of service.
- Promotes individual professional growth and development by
meeting requirements for mandatory/continuing education and skills
competency; supports department-based goals which contribute to the
success of the organization; serves as preceptor, mentor and
resource to less experienced staff.
- Other duties as assigned.
Must be able to demonstrate knowledge and skills necessary to
provide care appropriate to the patient served. Must demonstrate
knowledge of the principles of growth and development as it relates
to the different life cycles. Specific age groups that are served
by this position are circled:
| Neonate | Infant | Pediatric | Adolescent | Adult |
Keywords: Memorial Hermann Health System, Houston , Medical Director, Case Management, Other , Humble, Texas
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