| Provides leadership and operational oversight for the Utilization performance improvement and operational management of Case Management function at the Detroit Medical Center. Ensures consistent and coordinated delivery of all Utilization Management processes within the health system, including but not limited to, application of medical necessity criteria evaluation at all entry points, concurrent application of utilization management, timely submission of clinical reviews to third party payers, facilitation of physician secondary review process, and identification of resource utilization opportunities. Ensures documentation by staff is complete and coordination of all hospital-level and corporate staff involved in the Utilization Management process. Has overall responsibility for the Detroit Markets utilization performance improvement and operational management of the Case Management Department in order to promote effective utilization of system resources, ensure processes support appropriate reimbursement for services rendered, support efficient patient throughput, and ensure compliance with all state and federal regulations related to case management services. |
This position integrates national standards for case management scope of services including:
• Utilization Management supporting medical necessity and denial prevention • Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction • Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care • Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy • Education provided to physicians, patients, families and caregivers
Responsibilities include the following activities: a) manage department operations to assure effective throughput and reimbursement for services provided, b) lead the implementation and oversight of the system Utilization Management Plan using data to drive hospital utilization performance improvement, c) ensure medical necessity review processes are completed accurately and in compliance with CMS regulations and Tenet policy, d) ensure timely and effective patient transition and planning to support efficient patient throughput, e) implement and monitor processes to prevent payer disputes, f) develop and provide physician education and feedback on hospital utilization, , g) ensure compliance with state and federal regulations and TJC accreditation standards, and h) other duties as assigned. As directed, implements external and internal audit recommendations. Ensures hospital departments achieve objectives for diversity of their suppliers.