Utilization Manager

This is a fully remote position, open to applicants in North Carolina.

📋 Description

• Evaluate the accuracy of patient classification/status assignments in relation to clinical conditions, physician intentions, utilization review outcomes, regulations, and compliance requirements.

• Assist in medical chart audits by providing precise and timely clinical review documentation that supports medical necessity and the appropriate level of care.

• Record activities related to denial adjudication and proactively work to reverse potential denials.

• Verify authorization for hospitalized patients and commercial initiatives within the stipulated contractual timelines.

• Oversee concurrent cases through resolution that influence payer approval for medically necessary treatments.

• Conduct initial and ongoing stay reviews in accordance with the utilization management strategy.

• Examine records for medical necessity and engage with physicians and care teams for collaboration.

• Determine and communicate expected length of stay and projected discharge dates utilizing GMLOS.

• Implement evidence-based clinical review screening criteria and refer instances of failed criteria to the Physician Advisor or appeals process.

• Enable denial mitigation and facilitate peer-to-peer discussions.

• Collaborate with case managers, social workers, physicians, and care teams regarding discharge planning and utilization management strategies.

• Ensure that orders accurately reflect billing patient status and work closely with Physician Advisors, compliance, and revenue cycle teams.

• Provide training to physicians and healthcare teams about utilization review and compliance standards.

• Maintain strong relationships with both internal and external stakeholders and ensure effective communication for care coordination.

• Participate in a hospital committee.

• Contribute to quality and performance improvement initiatives related to resource utilization, care delivery, patient flow, capacity management, and clinical cost reduction.

• Conduct retrospective reviews of medical necessity and prepare written appeals for relevant post-bill audits and denials.

• Deliver education and constructive feedback to Utilization Managers and healthcare providers.

• Proactively screen and evaluate high-risk, potential readmissions, and patients admitted through the emergency department.

• Work with ED treatment teams to avoid inappropriate admissions and support community referrals and post-discharge planning.

• Aid in the transition from the ED to inpatient care.

⛳️ Requirements

• Bachelor of Science in Nursing (BSN) is mandatory.

• A minimum of three years of recent experience in acute clinical practice or a related healthcare field is required.

• Case Management Certification (ACM, CCM, or ANCC) must be obtained within two years of employment.

• Current or compact RN licensure in the state of North Carolina is essential.

• Basic Life Support (BLS) certification is required.

• Proficiency in basic computer skills is necessary.

• Capability to become adept at navigating and interpreting an electronic health record is important.

• Ability to effectively perform in a self-directed capacity while managing multiple tasks is crucial.

• Daily problem-solving of complex issues is expected.

• Excellent written and verbal communication skills are essential.

• Basic proficiency in Microsoft Word, PowerPoint, and Excel is required.

🏝️ Benefits

• Relocation Assistance may be available based on eligibility.

• Duke University Health System is recognized as a Magnet organization.

• Nurses across each hospital are annually acknowledged as North Carolina's Great 100 Nurses.

• The Duke University Health System employs over 6000 registered nurses.

• Commitment to equal employment opportunities and non-discrimination.

• Information and provisions for reasonable accommodations are readily available.