Clinical Utilization Manager

2 days ago


Detroit, Michigan, United States Detroit Medical Center Full time
About the Role

We are seeking an experienced Clinical Utilization Manager to join our team at the Detroit Medical Center. This is a full-time, day shift position that requires 36 hours of work per week.

Responsibilities
  • Balancing clinical and financial requirements and resources in advocating for patient needs with judicious resource management
  • 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
  • Completes admission reviews for all payors and sending admission reviews for payors with an authorization process
  • Completes concurrent reviews for all payors and sending concurrent reviews to payors with an authorization process
  • Closes open cases on the incomplete UM Census
  • Completes the Medicare Certification Checklist on applicable admissions
  • Discusses with the attending status changes, order clarifications, observation to inpatient changes for all payors
  • Reviews the OR, IR and cath lab schedule with follow-up as indicated
  • Identifies and documents Avoidable Days
  • Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay and discharge) compared to evidence-based practice, internal and external requirements.
  • Provide denial information for UR Committee, Denial and Revenue Cycle
  • Collaborate with Patient Access, Case Management, Managed Care and Business Office to improve concurrent review process to avoid denial or process delays in billing accounts
  • Accountable to identify and reports variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements. This priority includes documentation in the Tenet Case Management documentation system to communicating information through clear, complete and concise documentation
About Us

The Detroit Medical Center is a nationally recognized health care system that serves patients and families throughout Michigan and beyond. We have a legacy of caring for the people and the families that call Metro Detroit home; they're our neighbors, our friends, and our community.

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


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