Job Summary – Provides for the management and oversight of the utilization management and payment transactional functions for ACM payer division as well as providing subject matter expertise in matters related to improving the care and lowering the costs of the plan and the plans’ member at highly experiential level.
Participate in monitoring all departmental processes to identify opportunities for improvement and efficiency
Manage team-specific and/or departmental projects, as assigned
Track and report any compliance or publicity risks including root cause analysis and any corrective actions
Develop, review, revise and monitor medical policies and procedures to ensure that all work of the department meets all regulatory and accrediting standards for all products.
Continuously work to identify and implement administrative efficiencies within the department
Provide physician support and leadership for care management and care planning activities for all products as required
Interfaces with medical directors of other Ascension owned or partnered health plans
Oversees utilization management parameters of the Ascension SmartHealth benefit plan
Provide clinical and medical policy expertise for all aspects of UM
Lead implementation of prior authorization for imaging and hospitalization.
Review all cases denied by the clinical staff using the Medecision-Aerial documentation program.
Perform clinical review of prospective, concurrent, and retrospective benefit requests for both medical necessity and eligibility under the benefit plan
Ensure all regulatory, operational and documentation standards and reporting needs are met
Perform clinical review of both standard and expedited benefit appeals for any services requiring pre-authorization
Participate in inter-rater reliability exercises
Perform DRG and bridging reviews
New Technology Assessment
Establish and reinforce processes for implementing various inputs of information to support all lines of business including assessing and implementing new technology as relates to associate clinical care and experience
Designs and implements appropriate model for coverage of emerging technology and treatments
Works in conjunction with the Resource Group, St. John Providence Laboratory to provide input and leadership on the Pharmacogenetics testing project.
Evaluates and develops policy for all current and upcoming genetic tests.
Oversees the monitoring of quality and production standards through the interpretation of data and metrics. Oversees service level agreements
Lead appeals committees needed for regulatory and clinical management of plans
Perform provider claims dispute reviews
Support the provider inquiry line
Serves on ACM quality committee as needed
Provide leadership for NCQA accreditation as needed
Assist in the development of credentialing policies as needed.
High Cost and Complex Cases
Assist in making claim eligibility decisions in conjunction with and the plan’s stop loss carrier with respect to experimental and investigative treatments , medical necessity of treatment plan as well as any other possible stop loss coverage issues
Works with plan’s stop loss carrier to control plan costs through claim management activities as identified and executed by stop loss carrier
Claims Related Clinical Support
Provide physician expertise for the development/modification of claims payment
Network Team Clinical Support
Works with VP of Network Development for physician led committee structure for ACM
Interfaces with ACM clinical and network team and analytics team
Associate Health and Well-Being
Oversee Associate wellness plan including design and monitoring of program
Working with Associate Health, Occupational Health, and Workman’s comp, helps coordinate the delivery of high value, low cost services to our associates concerning wellness and their work environment
Develops health improvement interventions for behavioral health and opiate usage.
Pharmacy Related Services
Works with the benefits team to manage all aspects of the pharmacy benefit manager relationship
Works with the ABS-USHH team to manage all aspects of the specialty medical benefit pharmacy benefit manager relationship
Other duties as identified
Reporting structure – Direct reporting to ACM Chief Clinical Officer with matrixed working relationships with head of payer and plan division, head of clinical and network division, Ascension senior clinical leaders
Licensed Physician MD/DO obtained prior to hire date or job transfer date. Board Certified in area of Speciality
Doctor of Medicine
Completion of an accredited medical school is required upon date of hire or job transfer date
Five (5) years of clinical experience in the practice of medicine is required upon date of hire or job transfer date. Five (5) years of experience in medical administration and/or a medical directorship with a demonstrated success in medical administrative matters is required upon date of hire or job transfer date.
Ascension is a faith-based healthcare organization dedicated to transformation through innovation across the continuum of care. As the largest non-profit health system in the U.S. and the world's largest Catholic health system, Ascension is committed to delivering compassionate, personalized care to all, with special attention to persons living in poverty and those most vulnerable.