Director - Case Management

Benefits Statement

At Tenet Healthcare, we offer a comprehensive benefit package that prioritizes your health, professional development, and work‑life balance. Available plans and programs include:

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off (PTO)
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee assistance program, employee discount program
• Voluntary benefits including pet insurance, legal insurance, accident and critical illness insurance, long‑term care, elder & childcare, auto & home insurance

Eligibility may vary by location and is determined by employment status.

Summary Description

Oversees hospital utilization performance improvement and operational management of the Site Case Management Department to promote effective utilization of hospital resources, ensure processes support appropriate reimbursement, support efficient patient throughput, and ensure compliance with all state and federal regulations related to case management services.

Integrates national standards for case management scope of services including:

• Utilization Management supporting medical necessity and denial prevention
• Transition Management promoting appropriate length of stay, readmission prevention, and patient satisfaction
• Care Coordination demonstrating throughput efficiency while ensuring care is the right sequence at an appropriate level of care
• Compliance with state and federal regulatory requirements, TJC accreditation standards, and Tenet policy
• Education to physicians, patients, families, and caregivers

Responsibilities

• Manage department operations to assure effective throughput and reimbursement.
• Lead implementation and oversight of the hospital Utilization Management Plan.
• Ensure medical necessity review processes comply with CMS regulations and Tenet policy.
• Ensure timely and effective patient transition and planning to support efficient throughput.
• Implement and monitor processes to prevent payer disputes.
• Develop and provide physician education and feedback on hospital utilization.
• Ensure compliance with state and federal regulations and TJC accreditation standards.
• Draft policy provisions and interpret department policies.
• Monitor staff quality and productivity, and develop improvement activities.
• Assist in developing and monitoring budget and assessing goal attainment.
• Implement external and internal audit recommendations.

Position Specific Responsibilities

Department Operations

• Maintain adequate staffing and skill mix across seven days.
• Support staffing requests using Tenet Case Management recommendations and budgetary guidelines.
• Host regular departmental meetings for updates and education.
• Complete initial and annual competency and evaluation reviews of staff.
• Apply InterQual Inter‑Rater Reliability (IRR) policy for competency.
• Develop action plans for staff below IRR match rates.
• Ensure orientation for new staff, including Tenet policies and Allscripts training.
• Monitor workflow to ensure timely medical necessity reviews, payer communications, authorizations, denials, and transition planning.

Utilization Management

• Ensure medical necessity reviews align with Tenet policy.
• Oversee submission of cases to Physician Advisor review.
• Communicate clinical data to payers for admission, level of care, length of stay, and post‑acute services.
• Advocate with payers to secure appropriate payment.
• Participate in Revenue Cycle meetings to research disputes and educate staff.
• Implement and monitor peer‑to‑peer review with payers.
• Promote prudent utilization balancing cost and quality.
• Monitor and report Avoidable Days and other utilization metrics.
• Lead hospital Medicare Performance Improvement initiatives.
• Use Crimson data for compliance reporting.
• Ensure CMS Follow‑up Important Message (IM) and HINN letters are delivered and documented.

Transition Management

• Ensure transition plan assessments completed within 24 hours of admission.
• Mandate use of electronic referral request for patient placements.
• Document patient choice per CMS regulations.
• Identify and report variances in care appropriateness.
• Ensure clear, complete, concise documentation in the Tenet Case Management system.

Care Coordination

• Collaborate with nursing and leadership on Patient Care Conferences and Complex Case Review.
• Participate in daily bed management meetings.
• Ensure patient plans of care are clinically appropriate and aligned with patient choice.
• Ensure appropriate sequencing of consults, testing, and procedures.
• Communicate patient needs and ensure team accountability.
• Collaborate with all care team members to achieve optimum clinical outcomes.

Education

• Educate physicians on medical necessity, documentation, and regulatory compliance.
• Provide data to physicians and the hospital on resource utilization.
• Educate case management staff, physicians, and team on care progression, level of care, and timely transition.

Compliance

• Ensure compliance with federal, state, and local regulations.
• Maintain department structure, policies, and procedures in line with CMS and Tenet policies.
• Operate within RN scope of practice as defined by state licensing regulations.
• Monitor Tenet Case Management practices for compliance.

Qualifications

• Bachelor’s degree in Nursing or health‑related field, or equivalent education/experience; Master’s in Nursing, Business Administration, or Hospital Administration preferred.
• Registered Nurse or LCSW/LMSW license; must be currently licensed in the state(s) covered.
• Three to five years of acute hospital case management leadership experience; five years preferred.
• Master’s Social Work for MSW, and accredited case manager (ACM) preferred.
• InterQual® experience, business planning experience preferred.

Skills Required

• Analytical and advisory skills for strategizing and system evaluation.
• Fiscal skills for cost and revenue control.
• Ability to manage stressful situations and competing priorities.
• Strong communication and interpersonal skills for stakeholder persuasion and negotiation.
• Teaching abilities for educational programs.
• Project management skills for program, project, or process execution.
• Leadership skills with coaching and alliance building.
• Technical knowledge of community resources, regulatory requirements, reimbursements, and utilization procedures.

Facility Description

DMC Detroit Receiving Hospital is Michigan’s first Level I Trauma Center, with a busy emergency department, the state’s leading 24/7 hyperbaric oxygen program, Metro Detroit’s first certified primary stroke center, and recognized geriatric center of excellence.

EEO Statement

Employment practices will not be influenced by 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. Tenet participates in the E-Verify program.

Job Information

• Job: Case Management
• Primary Location: Detroit, Michigan
• Facility: DMC Receiving Hospital
• Job Type: Full Time
• Shift Type: Day

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