Utilization Manager

Tenet Healthcare Corporation; Detroit (MI); On-site; USD 120,000 - 160,000; Full time

Benefits offered by this job

Medical, dental, vision, and life保险

401(k) retirement plan with employer 1

Generous PTO

Career development and continuing教育

Health savings accounts

Employee Assistance program

Employee discount program

Pet insurance

Legal insurance

Accident and critical illness coverage

Long term care

Elder care

Auto and home insurance

Job summary

Detroit Medical Center is seeking a healthcare leader to drive excellence in Utilization Review and Case Management, ensuring medical necessity and appropriate levels of care while promoting timely throughput and safe discharge.

The role includes educating physicians and staff, coordinating with payers, and reporting to hospital leadership on utilization metrics and denials data, within Tenet's standards.

Qualifications

• Leader with experience in healthcare operations.
• Experience coordinating Utilization Review and Case Management.
• Strong knowledge of regulatory requirements and accreditation standards.

Responsibilities

• Facilitate and support an effective Utilization Review program within Case Management.
• Ensure care is provided at the appropriate level based on medical necessity.
• Negotiate with payers on a case-by-case basis for timely payments.
• Provide education to physicians and Case Management staff as needed.
• Generate reports and monitor utilization metrics for leadership.

Skills

Leadership

Healthcare management

Utilization review

Case management

Regulatory compliance

Job description

Job Description

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