Utilization Manager

coordinate activities of a diverse group of people in a fast-paced environment, critical thinking and problem solving skills and computer literacy.

Facility Description

The Detroit Medical Center (DMC) is a nationally recognized health care system that  serves patients and families throughout Michigan and beyond. A premier healthcare  resource, our mission is to help people live happier, healthier lives. The hospitals of  the Detroit Medical Center are the Children's Hospital of Michigan, Detroit Receiving  Hospital, Harper University Hospital, Hutzel Women's Hospital, the DMC Heart  Hospital, Huron Valley-Sinai Hospital, the Rehabilitation Institute of Michigan and Sinai-Grace Hospital.

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JOIN OUR TEAM

 QUALITY CARE DELIVERED BY COMPASSIONATE PEOPLE

We know it takes a special person to work in healthcare, and we are committed to providing our people with an enriching and rewarding environment. We deliver the resources, tools and support our employees need to serve our patients and customers in the best way possible — so we can create happier, healthier communities. 

COMMITTED TO DIVERSITY AND INCLUSION

At Tenet, we believe in a diverse and inclusive environment, one that is grounded in our dedication to the health and well-being of all people. Respecting, nurturing and encouraging diversity of thought, background and experience contribute to positive work environments that result in exceptional patient care. We embrace diversity because it's our culture, and because it's the right thing to do.

Are you a results-driven leader ready to make a meaningful impact to patients, caregivers, and  your community? At The Detroit Medical Center (DMC) , we’re  seeking an innovative and experienced healthcare leader to drive excellence and inspire our team  towards exceptional patient outcomes and  operational success.

Benefit Statement
At Tenet Healthcare, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:
•    Medical, dental, vision, and life insurance
•    401(k) retirement savings plan with employer match
•    Generous paid time off (PTO)
•    Career development and continuing education opportunities
•    Health savings accounts, healthcare C dependent flexible spending accounts
•    Employee Assistance program, Employee discount program
•    Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder C childcare, auto C home insurance.

Note\: Eligibility for benefits may vary by location and is determined by employment status

The individual in this position is responsible to facilitate and support an effective Utilization Review program within the Case Management department, which may be centralized within a specific market or group. The individual in this position has overall responsibility to ensure that care is provided at the appropriate level of care based on medical necessity and assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable readmissions. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case by case basis. This position integrates national standards for case management scope of services to include:

·       Provides assistance to the Director of Case Management in the management of the Utilization Review/ Central Utilization Review department, but not limited to, hiring/training/managing staff, schedule coordination, analysis and reporting, interfacing, collaborating and working closely with the other departments.

·       Accountable for compliance with state and federal regulatory requirements, TIC accreditation standards and Tenet policy.

·       Provides education to physicians, physician advisors, Case Management staff, and other hospital leaders as needed. Identify and provide physician education and feedback on hospital utilization and disputes/denials data.

·       Review weekly Case Management Utilization Review (UR) and Continuing Care (CC) scorecards/metrics, Observed/Expected Length of Stay, Authorizations and Downgrades. Provides reports to DCM and hospital leadership as requested.

·       Maintains knowledge of current contractual arrangements with Health Plans and Vendors. Partners with Managed Care representatives in JOC and other payer meetings to collaborate and communicate better outcomes.

·       Organize the concurrent authorization process to meet utilization management needs and monitor turn-around times to meet health plan requirements. Implement and monitor processes to prevent payer disputes.

·       Ensure medical necessity and revenue cycle processes are completed accurately and in compliance with Tenet policy as well as any state or federal program requirements.

The individual's responsibilities include the following activities\: a) accurate medical necessity screening and submission for Physician Advisor review, b) securing and documenting authorization for services from payers, c) managing concurrent disputes, d) collaborating with payers, physicians, office staff and ancillary departments, e) timely, complete and concise documentation in the Tenet Case Management documentation system, f) maintenance of accurate patient demographic and insurance information, g) identification and documentation of potentially avoidable days, h) identification and reporting over and underutilization, i) and other duties as assigned.