Director Registered Nurse; RN - Case Management

Job Title

Registered Nurse (RN) Case Management Director

Hamtramck, Michigan

Duration:
Ongoing

36 hours per week – 12 hour shifts

Employment type:

Staff

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

• Manage department operations to assure effective throughput and reimbursement for services provided.
• Lead the implementation and oversight of the hospital utilization management plan, using data to drive performance improvement.
• Ensure medical necessity review processes are completed accurately in compliance 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, federal, and TJC accreditation standards.
• Draft policy provisions and provide interpretation of department policies per the DMC Utilization Review Plan.
• Maintain adequate skill mix and staffing over seven days a week.
• Hold departmental meetings, complete staff competency reviews, and monitor productivity.
• Build and maintain relationships with physicians, nurses, and payers.

• Implement business case staffing requests in accordance with Tenet recommendations and budgetary guidelines.
• Provide regular updates and ongoing education to staff.
• Ensure new staff complete orientation and training.

• Implement and monitor medical necessity review processes and physician advisor reviews.
• Communicate clinical data to payers for admission, level of care, and post‑acute services.
• Advocate for the patient and hospital with payers to secure appropriate payment.
• Participate in revenue cycle meetings and analyze disputes.
• Conduct physician peer‑to‑peer reviews to resolve denials.
• Promote prudent utilization of resources, balancing cost and quality.
• Monitor and report avoidable days and other metrics.
• Serve as lead for Medicare performance improvement initiatives.

• Ensure transition plan assessment is completed within 24 hours of admission.
• Monitor documentation of patient choice per CMS regulations.
• Use electronic referral request process for patient placements.

• Work with nurses and leadership on patient care conferences and complex case reviews.
• Participate in bed management meetings to support placement and transfer.
• Ensure clinical, patient‑choice, and resource‑based plans of care.
• Coordinate testing and procedures sequencing.
• Collaborate with the care team to achieve optimal clinical outcomes.

• Provide education to physicians on medical necessity and regulatory compliance.
• Educate case management staff and the care team on care progression, appropriate level of care, and safe transition.

• Ensure compliance with federal, state, and local regulations and TJC accreditation.
• Maintain Tenet Case Management practices.
• Operate within RN scope of practice per state licensing regulations.

• Bachelor’s degree in Nursing or related field, or equivalent combination with experience. Master’s preferred.
• Registered Nurse or LCSW/LMSW license; active license(s) as required.
• Three to five years of acute hospital case management leadership experience; five years preferred.
• Accredited Case Manager preferred.

• Analytical ability to develop strategies and processes.
• Fiscal skills to monitor costs and revenue.
• Stress tolerance and multitasking.
• Strong communication, negotiation, and presentation skills.
• Teaching abilities for staff education.
• Project management skills.
• Leadership skills and ability to inspire others.
• Technical knowledge of community resources, reimbursement, and utilization management.

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

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex, 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.