Group Utilization Review Director

Description

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

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.

Utilization Management

Monitors the review process to ensure medical necessity patients to be in the appropriate status and level of care per Tenet policy
Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
Oversees submission of cases to Physician Advisor to ensure timely referral, follow up and documentation
Monitors the timely communication clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services
• Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
• Participates in Revenue Cycle meeting, researching disputes, uncovering patterns/trends and educating hospital and medical staff on actionable items
• Implements and monitors physician “peer to peer” review process with payers to resolve denials or downgrades concurrently
• 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
• Utilizes data to provide timely and meaningful information to the Utilization Management Committee and physician staff for performance improvement.
Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
• Identifies and documents Avoidable Days using the data to address opportunities for improvement
• Prevents denials and disputes by communicating with payers and documenting relevant information
• Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) compared to evidence-based practice, internal and external requirements.
(50% daily, essential)

Payer Authorization

Assures 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 payers to support admission, level of care, length of stay and authorization
Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
Prevents denials and disputes by communicating with payers and documenting relevant information
Manages payer dispute processes utilizing secondary review, peer to peer and payer type changes
(30% daily, essential)

Education

Ensures and provides education to physicians and physician advisors relevant to the
Effective progression of care,
Appropriate level of care, and
Safe and timely patient transition
Provides healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options
May, if licensed RN, oversee work delegated to Utilization Review LVN/LPN and/or Authorization Coordinator.
(10% daily, essential)

Compliance

• Ensures 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
• If licensed RN, operates within the RN scope of practice as defined by state licensing regulations
• Remains current with Tenet Case Management practices
(10% daily, essential)

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