RN Utilization Review Full Time Days

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.

DMC's 150-year legacy of medical excellence and service provides patients and families world-class care in cardiovascular health, women's services, neurosciences, stroke treatment, orthopedics, pediatrics, rehabilitation, organ transplant and other general and specialty services.

DMC is a key partner in Detroit's resurgence, which continues to draw national and international attention. A dedicated corporate citizen with strong community ties, DMC is one of the largest and most diverse employers in Southeast Michigan.

Summary / Description

The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care provided is at the appropriate level of care based on medical necessity. This position manages the medical necessity process for accurate and timely payment for services that may require negotiation with a payor on a case-by-case basis. This position integrates national standards for case management scope of services including:

• Utilization Management services supporting medical necessity and denial prevention
• Coordinating with payors to authorize appropriate level of care and length of stay for medically necessary services required for the patient
• Collaborating with Care Coordination by demonstrating efficient throughput while assuring care is sequenced and at the appropriate level of care
• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
• Educating payors, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits and compliance

The individual’s responsibilities include the following activities:

• Securing and documenting authorization for services from payors

• Performing accurate medical necessity screening and timely submission for Physician Advisor reviews

• Collaborating with payors, physicians, office staff and ancillary departments

• Managing concurrent disputes

• Identification and reporting over and underutilization

• Timely, complete, and concise documentation in Tenet Case Management documentation system

• Maintenance of accurate patient demographic and insurance information

• Identification and documentation of potentially avoidable days

• Other duties as assigned.

POSITION SPECIFIC RESPONSIBILITIES:

Utilization Management

• Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
• Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
• Completes admission reviews for all payors and sending admission reviews for payors with an authorization process
• Completes concurrent reviews for all payors and sending concurrent reviews to payors with an authorization process
• Closes open cases on the incomplete UM Census
• Completes the Medicare Certification Checklist on applicable admissions
• Discusses with the attending status changes, order clarifications, observation to inpatient changes for all payors
• Reviews the OR, IR and cath lab schedule with follow-up as indicated
• Identifies and documents Avoidable Days
• Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay and discharge) compared to evidence-based practice, internal and external requirements.
• Provide denial information for UR Committee, Denial and Revenue Cycle
• Collaborate with Patient Access, Case Management, Managed Care and Business Office to improve concurrent review process to avoid denial or process delays in billing accounts
• Accountable to identify and reports variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements. This priority includes documentation in the Tenet Case Management documentation system to communicating information through clear, complete and concise documentation
• (60% daily, essential)

Payor Authorization

• Advocates for the patient and hospital with payor to secure appropriate payment for services rendered
• Ensures the patient is in the appropriate status and level of care based on Medical Necessity and submits case for Secondary Physician review per Tenet policy
• Ensures timely communication and documentation of clinical data to payors to support admission, level of care, length of stay and authorization
• Prevents denials and disputes by communicating with payors and documenting relevant incoming and outgoing payor communications including denials, disputes and no authorizations in the case management system
• Follows the payor dispute processes utilizing secondary medical review, peer to peer and payor type changes
• (25% daily, essential)

Education

• Ensures and provides education to physicians and the healthcare team relevant to the effective progression of care and appropriate level of care
• Mentor and monitor work delegated to Utilization Review LVN/LPN and/or Authorization Coordinator as needed.
• (5% daily, essential)

Compliance

• Adheres to compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
• Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies
• Operates within the RN scope of practice as defined by state licensing regulations
• Remains current with Tenet Case Management practices
• (10% daily, essential)

Minimum Qualifications

• BSN preferred. At least two (2) years acute hospital or Behavioral Health patient care experience required. One (1) year hospital acute or behavioral health case management experience preferred.

• Active and valid RN license required. Accredited Case Manager (ACM) preferred.

Skills Required

• Analytical ability, critical thinking, problem solving skills and comprehensive knowledge base to identify opportunities for improvement and problem resolution, evaluate patient status and health care procedures/techniques, and monitor quality of patient care.

• Knowledge of care delivery capabilities along the continuum of care.

• Interpersonal skills to work productively with all levels of hospital personnel.

• Resourcefulness to identify prompt and sustainable solutions to barriers in care delivery.

• Verbal and written communication skills to communicate effectively with diverse populations including physicians, colleagues, patients, and families.

• Teaching abilities to conduct educational programs for staff.

• Flexibility with schedule, including off-shifts, weekends, and holidays in order to meet the needs of patients, families or staff.

• Organizational skills and ability to lead and coordinate activities of a diverse group of people in a fast-paced environment, and direct others toward objectives that contribute to the success of the department.

• Ability to cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously.

• Computer literacy to utilize case management systems.

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.