Regional Medical Director, Care Management and Utilization Review- UPMC Presbyterian/ Shadyside

The Regional Medical Director, CC/DP and Utilization Review, provides clinical and management leadership across multiple hospitals within the region. This role focuses on improving patient flow, resource utilization, and length of stay (LOS) strategic oversight. The Medical Director will report to the Vice President of Care Coordination, Discharge Planning, and Hospital Medicine, and will collaborate closely with local hospital VPMAs and presidents.

The Regional Medical Director will have direct reports, including Physician Advisors at UPMC Presbyterian/ Shadyside Hospital.

Key Responsibilities

• Leadership & Management
• Oversee Utilization Management (UM) across assigned hospitals, ensuring alignment with UPMC's mission, vision, values, and regulatory requirements.
• Lead and mentor Physician Advisors and other key medical staff leaders providing training and support to ensure consistent and effective UM practices.
• Foster strong partnerships with local hospital leadership, including VPMAs and hospital presidents, Director of CC/DPM, hospitalists, ED Directors, CNOs, and regional CNOs.
• Directly supervise and provide guidance to Physician Advisors at each hospital within the region.

Clinical & Operational Oversight

• Utilize measurable standards to monitor and improve the quality and cost-effectiveness of patient care.
• Analyze utilization data to identify trends and implement strategies to enhance medical appropriateness, LOS, and reduce denials.
• Direct UM functions, collaborating with CC/DP, clinical teams, and attending physicians to optimize care delivery and resource use.

Communication & Collaboration

• Serve as a liaison and consultant for internal UM functions, promoting effective communication and problem resolution.
• Facilitate interactions between managed care organizations, providers, and payers to address benefit coverage, utilization review, and quality assurance.
• Promote adherence to URAC standards, and regulatory requirements, including CMS policies.

Process Improvement

• Identify, address and remove avoidable delays, collaborating with CC/DPM, clinical nursing, and physicians to streamline care processes.
• Implement/adhere GMLOS goals using system-wide care plans, order sets, and discharge plans to ensure efficient, evidence-based care.
• Documentation & Compliance**:
• Maintain clear and concise documentation of all physician advisory activities in the UPMC Care Management information system.
• Conduct or coordinate concurrent appeals for denied or downgraded coverage determinations by payers.

Additional Responsibilities

• Perform other duties as assigned, adhering to system-wide competencies and behaviors.

Qualifications

• Strong leadership and communication skills.
• Comfortable with difficult conversations.
• Partnership approach to work.
• Interprofessional focus on work and team building.
• Proven ability to collaborate effectively with hospital administration and clinical teams.
• Experience in utilization management and care coordination.
• In-depth understanding of regulatory requirements and standards.

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