Registered Nurse (RN) - Case Management - $31+ per hour New

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

Job Description & Requirements

• Specialty: Case Management
• Discipline: RN
• Duration: Ongoing
• 36 hours per week
• Shift: 12 hours
• Employment Type: Staff

Children’s Hospital of Michigan is an international leader in pediatric and adolescent medicine. Surgical services include general, thoracic, reconstructive and cardiovascular. Imaging technology designed specifically for children provides advanced diagnostic services including Positron Emission Tomography (PET) and MRI. The Children’s Hospital of Michigan Emergency Department is a verified Level 1 Pediatric Trauma Center and dedicated pediatric burn center. Experts in pediatric critical care, rehabilitation, and neonatal and perinatal medicine provide care for thousands of children every year at Children’s Hospital of Michigan, Children’s Hospital of Michigan - Troy and six ambulatory sites.

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:

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

Job: Managers and Directors Primary Location: Detroit, Michigan Facility: DMC Children's Hospital of Michigan Job Type: Full Time Shift Type: Day

Detroit Medical Center Job ID #4​3​6​9​-​2​5​0​6​0​0​1359-0. Posted job title: Group Director of Case Management

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. 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; one that is often referred to as “my forever family” and “colleagues who have my back”. 

The DMC has a proud legacy of caring for the people and the families that call Metro Detroit home; 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. There’s a spirit of caring and togetherness that you will experience when you join the DMC family. We are a community build on care.

At the DMC, we are committed to maintaining an environment of Equal Opportunity and Affirmative Action. 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.

Employee Benefits

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. Basic life insurance and Accidental Death and Dismemberment insurance are provided for free to eligible plan members. 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.

Benefits

• Medical benefits
• Dental benefits
• Vision benefits
• Employee assistance programs
• Life insurance
• Discount program