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 works under the direction of RN Case Manager and/or Social Worker. The individual�s responsibilities include but are not limited to the following actions:

1. Follow-up on patient accounts when authorization for stay is required. Fax numbers to send clinical reviews.
2. Follow-up on each account during the stay and on discharge for authorization - document in the electronic system.
3. Escalate any potential disputes or denial of accounts to Director of Case Management or designee.
4. Trends disputed claims by at least payor and physician.
5. Assist in obtaining authorization for patient discharged to skilled facilities or other post-acute care that require authorization.
6. Trend by payor and service any authorization not obtained by end of day.
7. Trend and track on denial prevention.
8. Other duties as assigned.

POSITION SPECIFIC RESPONSIBILITIES:

Utilization Management
� Validates patient�s demographic and payer information with patient/family and notifies Patient Access immediately if any corrections are needed
� Validates that all commercial/managed care discharges have an authorization for status and level of care provided and notifies Director of Case Management (DCM) or designee of variances
� Cases that require authorization are obtained daily by fax or phone and documentation is completed daily
� Escalate discharged cases at end of day that have no authorization or notification of dispute is provided by payor
� Concurrently make sure all clinical needed by payors and updates are provided by alerting Case Manager assigned to case and escalating to DCM if not completed timely
� Trend dispute/denial potential to DCM or designee by failure points in revenue cycle
� Prepare denial information for UR Committee, Denial and Revenue Cycle Meetings
� 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
� (85% daily, essential)

Transition Management
� Follow up on Authorization for post-acute services
� Makes referrals for post-acute services under the direction of the RN Case Manager or Social Work (SW) staff utilizing the Tenet Case Management documentation system
� Follow-up if referral requires an authorization by payor to discharge the patient
� Completes tasks as assigned by RN or LVN Case Manager and/or SW staff
� Makes copies, send faxes and complete phone calls to arrange post-acute services and to ensure that appropriate hospital information is communicated to post-acute providers
� Documents all referrals and tasks in the Tenet Case Management documentation system per Tenet policy
� Provides Important Message follow up letter to Medicare beneficiaries per Tenet policy and under the direction of the RN Case Manager or SW
� (10%daily, essential)

Compliance
� Adheres to 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
� (5% daily, essential)

Minimum Qualifications
1. High School diploma or equivalent required. Associate or Bachelor�s degree preferred.
2. Two (2) years of experience in clerical or healthcare field required. Acute hospital experience preferred.
3. Paramedic, EMT or Nursing Assistant certification preferred

Skills Required
1. Excellent organizational skills
2. Excellent verbal and written communication skills
3. Demonstrated problem solving skills, and computer literacy.
4. Data analytic skills preferred

Employment practices will not be influenced or affected by an applicant�s or employee�s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.