Registered Nurse RN - Utilization Review 31+ per hour

Detroit Medical Center
US - Michigan - Hamtramck
January 17, 2025
Medical

Detroit Medical Center is seeking a Registered Nurse (RN) Utilization Review for a nursing job in Hamtramck, Michigan.

& Requirements

Specialty:
Utilization Review
Discipline:
RN
Duration:
Ongoing
36 hours per week
Shift:
12 hours, days
Employment Type:
Staff

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

Detroit Medical Center Job ID #4***29-1.
Posted job title:
RN Utilization Review Full Time Days

About Detroit Medical Center

The 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 DMC is able to achieve these awards because of our exceptional employees.

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 evidence-based approach inspires confidence and spurs innovation.
It ensures that we are making treatment decisions based on our experience, on the best available research and our understanding of each patient as an individual.

Our commitment to our patients

Our commitment to patient care and improving patient outcomes is part of everything we do.
It's our mission.
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).
We offer an inclusive, diverse and supportive environment.
Knowi.

Read the full job description and apply online on the recuiter's web-site

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& Requirements

About Detroit Medical Center

Our commitment to our patients

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