Insurance Utilization Review Jobs in Detroit, MI

Are you a results-driven leader ready to make a meaningful impact to patients, caregivers, and your community? At The Detroit Medical Center (DMC), we're seeking an innovative and experienced healthcare leader to drive excellence and inspire our team towards exceptional patient outcomes and operational success.

Benefit Statement    

At Tenet Healthcare, we understand that our greatest asset is our dedicated team of professionals. That's why we offer more than a job - we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:  
Medical, dental, vision, and life insurance
401(k) retirement savings plan with employer match
Generous paid time off (PTO)  
Career development and continuing education opportunities 
Health savings accounts, healthcare & dependent flexible spending accounts
Employee Assistance program, Employee discount program
Voluntary benefits include pet insurance, legal insurance, accident and critical illness 
insurance, long term care, elder & childcare, auto & home insurance.
Note: Eligibility for benefits may vary by location and is determined by employment status              
  

Summary:

The Group Director, Utilization Review will perform the functions necessary to support and advance Tenet's Case Management strategy with the specific focus on Utilization Review for the designated Market. Will support the advancement of Centralized Utilization Review as a leader, mentor, and consultant. Will execute on strategic initiatives and will provide subject matter expertise for Case Management - Utilization Review regulations and standards, including ensuring compliance with all state and federal regulations.

POSITION SPECIFIC RESPONSIBILITIES:
The Group Director will be responsible for developing and maintaining procedure manuals for such activities as: UM annual work plan/evaluation and quarterly and semi-annual UM reports; oversight of daily operations of the UM team and optimizing denial mitigation processes.
Will partner with the Group DCM and Hospital Case Mgt. Leaders relating to Case Management scope of services, including utilization management, transition management promoting appropriate length of stay, readmission prevention and patient satisfaction. Will ensure effective utilization of resources, timely and accurate revenue cycle processes, denial prevention, and safe and timely patient throughput. Will integrate national standards for utilization management supporting medical necessity and denials prevention.

QUALIFICATIONS:

  Bachelor's degree in business, nursing or health care administration required. Advanced degree in business, nursing and/or healthcare administration, health science or related discipline preferred.

       A minimum of 5 years' experience in hospital revenue cycle function. Five (5) years in hospital Utilization Review Leadership preferred. Multi-site leadership experience preferred. Experience successfully implementing centralized Utilization Review teams for multi-hospital system strongly preferred. Working knowledge of CarePort and MIDAS documentation and reporting required. Project Management and Business Planning experience; strong analytical skills including use of Tableau and Excel; executive communication and presentation skills including ability to use PowerPoint.

       Accredited Case Manager (ACM) or Certified Public Accountant (CPA) preferred, Six Sigma Green Belt preferred

       Valid Registered Nurse (RN) preferred

PHYSICAL DEMANDS:

-Lift/position up to 25 lbs. Push/pull up to 25 lbs of force.

-Frequent sitting. Moderate standing, walking, reaching, stooping, and bending

-Manual dexterity, mobility, touch, auditory to perform all the related duties of the position

Facility Description

EEO Statement

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 13 legally protected status.

Tenet will make reasonable accommodation for qualified individuals with disabilities unless doing so would result in an undue hardship.

Tenet participates in the E-Verify program. Follow the link below for additional information.

E-Verify: http://www.uscis.gov/e-verify

The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations