Utilization Manager

Tenet • Detroit, MI

2d

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 and assesses patients’ transition needs to support timely throughput and safe discharge and to help prevent avoidable readmissions. The position manages the medical necessity process to support accurate and timely payment for services, including negotiating with payers on a case-by-case basis when needed.

The manager assists the Director of Case Management with management of the Utilization Review or Central Utilization Review department. Responsibilities include supporting staffing and schedule coordination, analyzing and reporting metrics, collaborating with other departments, maintaining regulatory and policy compliance, and educating physicians and hospital teams. The role also coordinates concurrent authorization processes, works with payers and Managed Care representatives, and monitors processes intended to prevent payer disputes.

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

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

Responsibilities

• Assist the Director of Case Management in managing the Utilization Review or 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 other hospital leaders as needed.
• Provide physician education and feedback regarding hospital utilization and disputes or 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 Director of Case Management and hospital leadership as requested.
• Maintain knowledge of current contractual arrangements with health plans and vendors.
• Partner with Managed Care representatives in JOC and other payer meetings to collaborate and communicate about better outcomes.
• Organize the concurrent authorization process to meet utilization management needs and monitor turnaround 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 and applicable state or federal program requirements.
• Conduct accurate medical necessity screening and submit cases for Physician Advisor review.
• Secure and document payer authorization for services.
• Manage concurrent disputes and collaborate with payers, physicians, office staff, and ancillary departments.
• Maintain timely, complete, and concise documentation in the Tenet Case Management documentation system.
• Maintain accurate patient demographic and insurance information.
• Identify and document potentially avoidable days.
• Identify and report overutilization 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