Utilization Manager

Tenet Healthcare • Detroit, MI

3d

About The Position

The Utilization Manager facilitates and supports an effective Utilization Review program within the Case Management department, which may be centralized within a market or group. The role ensures that care is provided at the appropriate level based on medical necessity, assesses patients’ transition needs to promote timely throughput and safe discharge, and helps prevent avoidable readmissions. The position manages the medical necessity process to support accurate and timely payment for services, including case-by-case negotiation with payers when needed.

The manager assists the Director of Case Management with management of the Utilization Review/Central Utilization Review department, including staff hiring, training and management, schedule coordination, analysis and reporting, and collaboration with other departments. The role is accountable for compliance with state and federal requirements, TIC accreditation standards, and Tenet policy. It also provides education to physicians, physician advisors, Case Management staff, and hospital leaders; reviews utilization and continuing-care metrics; and works with Managed Care representatives and payers to improve outcomes.

The position oversees concurrent authorization processes and turnaround times, works to prevent payer disputes, and ensures medical-necessity and revenue-cycle processes are accurate and compliant. Responsibilities also include screening for medical necessity, securing and documenting payer authorizations, managing concurrent disputes, maintaining accurate patient and insurance information, documenting potentially avoidable days, and identifying and reporting over- and underutilization.

Requirements

• Active Registered Nurse license.
• At least two years of experience in acute hospital patient care, hospital case management, utilization review, healthcare, or leadership.
• 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.
• Computer literacy.

Nice To Haves

• Bachelor of Science in Nursing (B.S.N.) preferred, unless a higher degree is required for Magnet Hospital Status.
• Accredited Case Manager (ACM) certification preferred.
• Acute hospital case management or supervisory experience preferred.

Responsibilities

• Assist the Director of Case Management in managing the Utilization Review/Central Utilization Review department, including hiring, training, and managing staff; coordinating schedules; analyzing and reporting; and collaborating with other departments.
• Ensure compliance with state and federal regulatory requirements, TIC accreditation standards, and Tenet policy.
• Educate physicians, physician advisors, Case Management staff, and hospital leaders as needed, including providing physicians with education and feedback on utilization and disputes/denials data.
• Review weekly Case Management Utilization Review and Continuing Care scorecards and metrics, Observed/Expected Length of Stay, authorizations, and downgrades; provide reports to the DCM and hospital leadership as requested.
• Maintain knowledge of current contractual arrangements with health plans and vendors, and partner with Managed Care representatives in JOC and other payer meetings.
• Organize the concurrent authorization process, monitor turnaround times to meet health plan requirements, and implement and monitor processes to prevent payer disputes.
• Ensure medical-necessity and revenue-cycle processes are completed accurately and comply with Tenet policy and applicable state or federal program requirements.
• Perform accurate medical-necessity screening and submit cases for Physician Advisor review.
• Secure and document payer authorization for services and manage concurrent disputes.
• Collaborate with payers, physicians, office staff, and ancillary departments.
• Complete timely, accurate, and concise documentation in the Tenet Case Management documentation system.
• Maintain accurate patient demographic and insurance information.
• Identify and document potentially avoidable days, and identify and report over- and underutilization.
• Perform other duties as assigned.

Benefits

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Paid time off (PTO)
• Career development and continuing education opportunities
• Health savings accounts
• Healthcare and dependent-care flexible spending accounts
• Employee Assistance Program
• Employee discount program
• Voluntary pet insurance, legal insurance, accident and critical illness insurance, long-term care, elder and childcare, and auto and home insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: No Education Listed