Job Title

Detroit Medical Center is seeking a Registered Nurse (RN) Utilization Review for a nursing job in Hamtramck, Michigan. Discipline:RN ~ Shift: 12 hours, days ~ Employment Type:StaffTheDetroit 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.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. 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 complianceSecuring 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 # 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 the Medicare Certification Checklist on applicable admissions ~ Identifies and documentsAvoidable 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. ~ 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. 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 ~(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. ~(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 ~ 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. 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. # Computer literacy to utilize case management systems.Job: Case Management/Home Health Primary Location: Detroit, Michigan Facility: Detroit Medical Center Shared Services Job Type: Full Time Shift Type: DayDetroit Medical Center Job ID #4369-2506001461-2. RN Utilization Review Full Time Days About Detroit Medical CenterThe Detroit Medical Center (DMC) is the leading academically–integrated hospital system in Metro Detroit, and one of the largest health care providers in Southeast Michigan. During our 150+ years of caring for the community, we have been recognized nationally with top awards in many aspects of hospital operations and patient care. The Detroit Medical Center is one the largest academic medical centers in the United States, with a long and rich history of medical education, for more than 100 years. We train more physicians than any other hospital in Detroit. Our commitment to patient care and improving patient outcomes is part of everything we do. It’s our promise to every patient and every family who entrusts their care to us. To meet the needs of our community, we operate 8 hospitals and more than 140 clinics and outpatient facilities across southeast Michigan, including a nationally recognized dedicated pediatric hospital (Children’s Hospital of Michigan) as well as a nationally recognized rehabilitation hospital (Rehabilitation Institute of Michigan). Knowing that we are better together, our teams are highly collaborative and integrated to deliver the high quality and compassionate care our patients expect and deserve. Staff members have a voice in forming our culture; they’re our neighbors, our friends, and our community. That’s why the DMC serves everyone in the community who needs us; no one gets turned away who comes to us for care. From local food drives to our long-standing commitment to educate and empower our community towards better health, you can count on the DMC. We are a community build on care. If you need a reasonable accommodation to access the information provided on this web site, please contact the DMC facility where the position is available, for further assistance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran status or status as an individual disability.At the DMC, health and well-being are important to us, so we provide a range of benefits and options to help meet the needs of all eligible employees. In addition to a range of healthcare plans, including higher and lower deductible options, we offer dental, vision and an employee assistance plan. Employees can also choose to participate in one of several supplemental life insurance and/or disability plans, a legal services plan and an identity protection plan. For those employees who are looking for support to care for family members, we also offer child and elder care programs. To help employees prepare for retirement, we offer a 401K savings plan, and an employee discount plan that includes discounts for a wide variety of products, including auto and home insurance and mobile plans. Medical benefits Dental benefits Employee assistance programs