Under limited direction and according to established policies and procedures, acts as a member of the care management team by applying medical necessity criteria to determine appropriate level of care at every patient access point. Access location points typically include acute care hospitals, post-acute venues, clinic, or home. Integrates Third Party payer specific agreement criteria, and interfaces with respective payer representatives. Communicates with patient, family, medical team, caregivers and third party payers as necessary. Analyzes case management outcome data to facilitate appeals and denials. Maintains current knowledge of health care techniques and practices by participating in educational programs. Participation in Utilization Review committee process as needed. Maintains a working knowledge of the requirements of the payers and admission criteria for this patient population.
Responsible for pre-admission assessment of patients referred for inpatient acute rehabilitation services, including making recommendations for alternate levels of care within the continuum if the patient is not a candidate for admission. Coordinates the gathering of pertinent patient information on all referred patients from various sources including medical record, onsite and telephonic interviews and through other electronic media for the purposes of pursuing insurance authorization or ensuring reasonable and necessary admission criteria are met. Communicates quickly and effectively with referral sources upon decision to admit. Consults with other members of the interdisciplinary team regarding potential admissions, as necessary. Participates in quality improvement activities as directed or necessary. Establishes and maintains effective relationships with physicians and all other staff members, internally and externally. Identifies problems or any dissatisfaction experienced by any customer or referring source and works to resolve them to a high degree of service excellence. Effectively turns negative situations into supportive relationships by use of concern, poise, understanding, honesty and tact. Exhibits behavioral skills that promote a positive customer relations environment. Performs other duties and functions as assigned.
Qualifications: Minimum Qualifications
1. Graduate from an accredited school of nursing. Bachelor's degree in Nursing or other health-related field, or equivalent combination of education and/or related experience.
2. Three to five years clinical/nursing experience. Previous related experience with the targeted patient population preferred.
3. License to practice as a Registered Nurse in the State of Michigan.
1. Analytical ability 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.
2. Fiscal skills to monitor and control costs and revenue; also a working knowledge of the revenue cycle and resulting impact of utilization management decisions.
3. Interpersonal skills to work productively with all levels of hospital personnel.
4. Verbal and written communication skills to communicate effectively with diverse populations including physicians, employees, patients and their families.
5. Proficiency in application of standard appropriateness criteria sets (e.g., InterQual).
6. Flexibility with schedule, including off-shifts, weekends and holidays in order to meet the needs of patients, families or staff.
7. Leadership skills to direct others toward objectives that contribute to the success of the department.
8. Ability to cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously.
9. Ability to integrate Third Party contractual arrangements in the pre-admission review process.
Job: Therapy and Rehabilitation
Primary Location: Detroit, Michigan
Facility: DMC Rehabilitation Institute of Michigan
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��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.
Internal Number: 1905040093
About DMC Rehabilitation Institute of Michigan
“Tenet Healthcare Corporation is a diversified healthcare services company with 115,000 employees united around a common mission: to help people live happier, healthier lives. Through its subsidiaries, partnerships and joint ventures, including United Surgical Partners International, the Company operates general acute care and specialty hospitals, ambulatory surgery centers, urgent care centers and other outpatient facilities. Tenet's Conifer Health Solutions subsidiary provides technology-enabled performance improvement and health management solutions to hospitals, health systems, integrated delivery networks, physician groups, self-insured organizations and health plans.