Utilization Manager

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

📋 Description

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

• Assist with medical chart audits by providing accurate and timely clinical review documentation that supports medical necessity and level of care.

• Aid in managing denial cases and document the activities involved in adjudicating those denials.

• Confirm authorization for admitted patients and commercial initiatives within stipulated contractual timelines.

• Oversee concurrent cases by resolving care-related issues that influence payer approvals.

• Perform initial and ongoing stay reviews as outlined in the utilization management plan.

• Examine records for medical necessity and work collaboratively with physicians and care teams.

• Establish and communicate the anticipated length of stay and expected discharge date using GMLOS.

• Utilize evidence-based clinical review screening criteria and refer unsuccessful cases to the Physician Advisor or the appeals process.

• Facilitate conversations aimed at mitigating denials and engage in peer-to-peer discussions.

• Collaborate on discharge planning, utilization management, care coordination, and transitions from the emergency department.

• Ensure that orders accurately reflect the billing patient status.

• Provide educational support to physicians and healthcare teams regarding utilization review and compliance.

• Participate in hospital committees as well as quality and performance improvement initiatives.

• Conduct retrospective medical necessity reviews and prepare written appeals for relevant audits and denials.

⛳️ Requirements

• A Bachelor of Science in Nursing (BSN) is required.

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

• Current or compact RN licensure in North Carolina is mandatory.

• Basic Life Support (BLS) certification is required.

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

• Basic computer skills are essential.

• Ability to effectively navigate and interpret electronic health records is required.

• Must be capable of working efficiently in a self-directed role while managing multiple tasks.

• Ability to resolve complex issues on a daily basis is necessary.

• Excellent written and verbal communication skills are required.

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

🏝️ Benefits

• Relocation Assistance (subject to eligibility).

• Affiliation with a Magnet organization and support for nursing certification advocacy.

• Commitment to equal opportunity employment.

• Support for reasonable accommodations.