Healthcare Utilization Specialist
4 days ago
In this challenging and rewarding role, you will play a vital part in ensuring that patients receive the most appropriate care while maintaining efficient resource utilization.
Responsibilities- You will facilitate effective resource coordination to help patients achieve optimal health outcomes, access to care, and appropriate utilization of resources.
- You will ensure that care provided is at the appropriate level of care based on medical necessity.
- You will manage the medical necessity process for accurate and timely payment for services that may require negotiation with a payor on a case-by-case basis.
This position integrates national standards for case management scope of services including:
- Utilization Management services supporting medical necessity and denial prevention
- Coordinating with payors to authorize appropriate level of care and length of stay for medically necessary services required for the patient
- Collaborating with Care Coordination by demonstrating efficient throughput while assuring care is sequenced and at the appropriate level of care
- Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
- Educating payors, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits and compliance
- Bachelor's degree in nursing or related field
- RN licensure in Michigan
- Experience in case management or utilization review preferred
We offer a competitive salary range of $90,000 - 120,000 per year, commensurate with experience, plus an excellent benefits package. The Detroit Medical Center is an equal opportunity employer committed to diversity and inclusion.
What We Offer- A dynamic and supportive work environment
- Ongoing education and training opportunities
- A comprehensive benefits package, including medical, dental, and vision coverage
- A generous retirement savings plan
- A discount program for employees and their families
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