Registered Nurse (RN) - Utilization Review

Company: Detroit Medical Center
Location: Hamtramck
Posted on: July 6, 2025

Job Description:

Job Description Detroit Medical Center is seeking a Registered Nurse (RN) Utilization Review for a nursing job in Hamtramck, Michigan. Job Description & Requirements - Specialty: Utilization Review - Discipline: RN - Duration: Ongoing - 36 hours per week - Shift: 12 hours, days - Employment Type: Staff /n 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 The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care provided is at the appropriate level of care based on medical necessity. This position manages 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 The individual’s responsibilities include the following activities: 1. Securing and documenting authorization for services from payors 2. Performing accurate medical necessity screening and timely submission for Physician Advisor reviews 3. Collaborating with payors, physicians, office staff and ancillary departments 4. Managing concurrent disputes 5. Identification and reporting over and underutilization 6. Timely, complete, and concise documentation in Tenet Case Management documentation system 7. Maintenance of accurate patient demographic and insurance information 8. Identification and documentation of potentially avoidable days 9. Other duties as assigned. POSITION SPECIFIC RESPONSIBILITIES: Utilization Management - Balances 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 - (60% daily, essential) Payor Authorization - Advocates for the patient and hospital with payor to secure appropriate payment for services rendered - Ensures 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 payors to support admission, level of care, length of stay and authorization - Prevents denials and disputes by communicating with payors and documenting relevant incoming and outgoing payor communications including denials, disputes and no authorizations in the case management system - Follows the payor dispute processes utilizing secondary medical review, peer to peer and payor type changes - (25% daily, essential) Education - Ensures and provides education to physicians and the healthcare team relevant to the effective progression of care and appropriate level of care - Mentor and monitor work delegated to Utilization Review LVN/LPN and/or Authorization Coordinator as needed. - (5% daily, essential) Compliance - Adheres to 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 - Operates within the RN scope of practice as defined by state licensing regulations - Remains current with Tenet Case Management practices - (10% daily, essential) Qualifications: Minimum Qualifications 1. BSN preferred. At least two (2) years acute hospital or Behavioral Health patient care experience required. One (1) year hospital acute or behavioral health case management experience preferred. 2. Active and valid RN license required. Accredited Case Manager (ACM) preferred. Skills Required 1. Analytical ability, critical thinking, problem solving skills and comprehensive knowledge base to identify opportunities for improvement and problem resolution, evaluate patient status and health care procedures/techniques, and monitor quality of patient care. 1. Knowledge of care delivery capabilities along the continuum of care. 1. Interpersonal skills to work productively with all levels of hospital personnel. 1. Resourcefulness to identify prompt and sustainable solutions to barriers in care delivery. 1. Verbal and written communication skills to communicate effectively with diverse populations including physicians, colleagues, patients, and families. 2. Teaching abilities to conduct educational programs for staff. 3. Flexibility with schedule, including off-shifts, weekends, and holidays in order to meet the needs of patients, families or staff. 4. Organizational skills and ability to lead and coordinate activities of a diverse group of people in a fast-paced environment, and direct others toward objectives that contribute to the success of the department. 5. Ability to cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously. 6. Computer literacy to utilize case management systems. Job: Case Management/Home Health Primary Location: Detroit, Michigan Facility: Detroit Medical Center Shared Services Job Type: Full Time Shift Type: Day Detroit Medical Center Job ID 4369-2506001461-1. Posted job title: RN Utilization Review Full Time Days 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

Keywords: Detroit Medical Center, Detroit , Registered Nurse (RN) - Utilization Review, Healthcare , Hamtramck, Michigan