Utilization Review Jobs in Rochester Hills, MI (NOW HIRING)

HAVENWYCK HOSPITAL (a UHS facility)

Havenwyck Hospital is a 243 bed Joint Commission accredited and licensed psychiatric hospital in Auburn Hills, Michigan. We specialize in providing comprehensive, compassionate behavioral health services to children, adolescents and adults.

For more information, please visit us at www.havenwyckhospital.com

Havenwyck Hospital is seeking a dynamic and talented Quality Improvement Specialist to join our team of compassionate, dedicated professionals.

The Lead Utilization Management (UM) Case Manager has responsibility for daily case assignments to the UM staff and the daily monitoring, tracking, and reporting of Medicare Certificates. The Lead UM Case Manager demonstrates understanding of the UM Review Process and acts as a resource for UM staff. The Lead UM Case Manager, under the direction of the Director of UM, develops procedures for UM departmental activities and processes. The Lead UM Case Manager has responsibility for organizing and conducting the managed care process. These duties shall be directed toward supporting the hospital's mission in the pursuit of excellence in care/service and will include (but not limited to): conducting timely admission and continued stay record reviews with external payers, utilizing approved criteria to make determinations of medical necessity and level of care planning, verifying active treatment by completing internal audit reviews within approved time frames, assisting the treatment team when indicated in the discharge planning process, and acting as liaison with MD/Clinical Treatment Team and external agencies. Report authorizations, denials, and documentation concerns, as well as collaborate effectively across departments to minimize denials/facilitate optimal use of hospital resources.

Lead Utilization Management (UM) Case Manager duties include but are not limited to:

• On a daily basis, monitors admissions and continued stay reviews for RTC. Conducts medical necessity audits and chart reviews as needed. Provides coverage for the department in the absence of the UM Manager.
• Manages the assignment of cases to the UM staff and ensures equitable distribution of caseload.
• Monitors, tracks and reports Medicare Certificates and ensures their accurate completion by contacting the appropriate staff or physician.
• Demonstrates higher understanding of the UM Review Process and acts as a resource for UM staff. Under the direction of the UM Manager or Director, develops/documents procedures for UM departmental activities and processes.
• Through clinical skills (experience and knowledge), reports to external insurance and review entities an accurate presentation of the medical management of a patient’s illness, length of stay and care alternatives available within the confines on the client’s benefits and financial resources.
• Communicates with the Treatment Team (physicians, nursing staff, social workers, etc.) as necessary to advocate for the patient’s clinical treatment within the confines on the client’s benefits and financial resources
• Using clinical skills (experience and knowledge) assists the team in ensuring the completeness and accuracy of the medical record.
• Conducts phone, online and fax reviews with managed care providers and relays clinical data in a professional, assertive, clear and organized manner
• Maintains a positive rapport with managed care providers; acts as a representative of Havenwyck Hospital.
• Communicates results of reviews with physicians and team via direct contact, phone calls and chart stickers. Communicates specific criteria and special requirement of managed care regarding discharge planning, family sessions, and treatment plans.
• Refers cases to the Physician Advisor/designee.
• Informs physician of need to contact the managed care reviewers and follows up to ensure call is made and ascertain the number of days obtained.
• Keeps accurate record of days assigned to patients and when the next review is necessary. Keeps accurate accounting of authorized days from admission to discharge.
• Monitors and tracks the certification and re-certification process for Medicare patients to make certain all state and federal reporting guidelines are met.
• Maintains a flow of information by documenting in internal electronic record (MIDAS) any information necessary for treatment team members to follow up on a case.
• Ensures accurate documentation of authorization status and provides appropriate information to the hospital fiscal department to assist in the timely filing of claims, which, in turn, facilitates the accurate and appropriate reimbursement for services rendered.
• Reviews cases on a daily basis, checking for discharges and day hospital admission and relaying pertinent information
• Acts as a facilitator for the provider, payor and patient in utilizing benefits in the most efficient and effectual manner.
• Has a working knowledge of insurance verification and benefits.
• Possess clinical skills including specific knowledge of diagnosis and dynamics involved in the treatment of psychiatric illnesses for patients of all ages.
• Attends hospital mandatory training/in-services as required in a timely manner.

WHAT DO OUR CURRENT EMPLOYEES VALUE AT HAVENWYCK HOSPITAL AND UHS?

An environment that puts patient care first. One of the most rewarding aspects of this job is providing excellent care, comfort, and security to the patients and families you treat, at their most vulnerable times. Supportive and responsive leadership. You are never alone, as you are part of a large network of peer co-workers that routinely exchange ideas and review current topics within the industry. Having the opportunity to grow, learn, and advance in your career. There are very robust continuing education options and opportunities for skills diversification and career advancement with UHS.

BENEFIT HIGHLIGHTS

• Student Loan Repayment
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plan
• 401(K) with company match and discounted stock plan
• Career development opportunities within UHS and its 300+ Subsidiaries
• Free Basic Life Insurance
• Tuition Reimbursement
• SoFi Student Loan Refinancing Program

Universal Health Services (UHS):

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 300 corporation, annual revenues were $15.8 billion in 2024. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies.

Headquartered in King of Prussia, PA, UHS has approximately 99,000 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com

• Master’s degree in social work, psychology, or counseling; or a Bachelor’s degree in nursing required.
• Unrestricted and fully licensed (RN, MSW, LLMSW, LMFT, LP, LPC, etc.) required.
• A minimum of 2 years of post-graduate related experience in psychiatric or substance abuse treatment required.
• Able to establish professional relationships with all healthcare providers, work independently and collaboratively, have strong communication and organizational skills and attention to detail, and able to follow and manage multiple patient cases concurrently.
• Experience in settings that include inpatient or partial hospitalization preferred.
• Experience with managed health care process, medical terminology, experience in case management, discharge planning, and/or utilization review preferred.
• Strong organizational, writing and speaking skills are required, as well as effective communication and interpersonal skills, the ability to work with a broad array of community-based service providers and an understanding of all applicable regularity guidelines.
• Experience with managed health care processes, medical terminology, experience in case management, discharge planning, and/or utilization review.
• Hospital utilization review/utilization management experience preferred.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

Avoid and Report Recruitment Scams

At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.

If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.

• Master’s degree in social work, psychology, or counseling; or a Bachelor’s degree in nursing required.
• Unrestricted and fully licensed (RN, MSW, LLMSW, LMFT, LP, LPC, etc.) required.
• A minimum of 2 years of post-graduate related experience in psychiatric or substance abuse treatment required.
• Able to establish professional relationships with all healthcare providers, work independently and collaboratively, have strong communication and organizational skills and attention to detail, and able to follow and manage multiple patient cases concurrently.
• Experience in settings that include inpatient or partial hospitalization preferred.
• Experience with managed health care process, medical terminology, experience in case management, discharge planning, and/or utilization review preferred.
• Strong organizational, writing and speaking skills are required, as well as effective communication and interpersonal skills, the ability to work with a broad array of community-based service providers and an understanding of all applicable regularity guidelines.
• Experience with managed health care processes, medical terminology, experience in case management, discharge planning, and/or utilization review.
• Hospital utilization review/utilization management experience preferred.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

Avoid and Report Recruitment Scams

At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.

If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.