Utilization Manager

Returning Applicant or New Applicant?; Detroit (MI); Presencial; USD 85.000 - 110.000; Tempo integral

Benefícios oferecidos por esta vaga

Medical insurance

Dental insurance

Vision insurance

Life insurance

401(k) with employer match

Paid time off (PTO)

Career development

Resumo da vaga

Detroit Medical Center (DMC) seeks a seasoned Utilization Manager to lead the Utilization Review program within Case Management, ensuring medical necessity and timely transition planning for safe discharges and reduced readmissions.

The role requires an active RN license with hospital case management or utilization review experience; BSN preferred and ACM certification encouraged. Strong leadership and communication skills are essential to collaborate across departments.

Qualificações

• Active RN license required with hospital experience in case management, utilization review or leadership.
• Bachelor of Science in Nursing (BSN) preferred; ACM certification preferred.
• Accredited Case Manager (ACM) preferred; Magnet Hospital status consideration may influence requirements.

Responsabilidades

• Facilitate and support an effective Utilization Review program within Case Management.
• Manage medical necessity process and negotiate with payers as needed.
• Provide education to physicians, staff, and leaders on utilization and denial data.

Conhecimentos

Organizational skills

Verbal and written communication

Leadership / team coordination

Critical thinking

Problem solving

Computer literacy

Formação

RN license

BSN preferred

ACM certification preferred

Descrição da vaga

Utilization Manager – 2606002748

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.

• 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.

Qualifications

Required qualifications include an active Registered Nurse license with at least two years acute hospital patient care, hospital case management, utilization review, healthcare, or leadership experience. B.S.N. preferred, ***unless higher degree required for Magnet Hospital Status. Accredited Case Manager (ACM) preferred. Acute hospital case management or supervisory experience preferred. Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and

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.

EEO Statement

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

Tenet participates in the E-Verify program. Follow the link below for additional information.

E-Verify: http://www.uscis.gov/e-verify

The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations

Job

Nursing

Primary Location

MI-Detroit

Hospital/Facility

Detroit Medical Center Shared Services

Scheduled Hours

80

Shift Type

Days

FTE

1.000000