Medical Director - Clinical Denial Recovery Unit (CDRU)/Payor Audit
GENERAL SUMMARY:
Reports to the Chief Utilization Officer (CUO) of Henry Ford Health, responsible for Clinical Denial Recovery Unit (CDRU) operations. Responsible for strategic and operational leadership and oversight of programs and initiatives including denials management, performance improvement, regulatory, compliance, and risk with an expectation of national top decile performance. This system role includes physician oversight and clinical input for post-discharge medical necessity denials at all HFHS acute care facilities.
PRINCIPLE DUTIES AND RESPONSIBILITIES:
1. Oversee a comprehensive value-driven centralized denial management process.
2. In collaboration with executive and administrative partners, provide clinical expertise to CDRU, Payor Audit, hospital UM teams, system IPAS, managed care contracting, and legal.
3. Participate as a clinical expert in payer negotiations and escalations, Accounts Receivable Reconciliation Group (AARGs) and Medical Director Meetings (MDMs), and during Administrative Law Judge (ALJ) hearings for denied cases.
4. Standardize and oversee a comprehensive reliability-driven process for status determination in concert with site level physician advisors.
5. Prepare and analyze denial metrics and make recommendations for process improvements.
6. Provide feedback to system IPAS regarding denial trends, opportunities for improvement, and payor practices.
7. Report out metrics and initiatives at Medical Executive and Executive Leadership meetings as requested.
8. Assist the manager of CDRU, UM Director, and Director of Payor Audit with preparation of case escalations for payer negotiations.
9. Assist the CDRU RN staff with medical necessity appeals for complex medical cases.
10. Maintain a working knowledge of applicable Federal, State and local laws and regulations, initiatives, and expectations as set by payers and CMS.
11. Collaborate with accountable leaders to develop processes that ensure consistent feedback for all involved care providers regarding specific denial mitigation strategies and performance results.
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EDUCATION/EXPERIENCE REQUIRED:
· Graduate of an accredited medical school, completion of a three (3) year U.S. residency program, and board certified in their specialty.
· Minimum seven (7) years of clinical practice as a physician.
· Previous performance-based leadership experience preferred.
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Additional Details
This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.
Overview
Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers.
Benefits
The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits.
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.