Utilization Manager

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

📋 Description

• Evaluate the accuracy of patient classification/status in relation to clinical conditions, physician intent, utilization review outcomes, regulations, and guidelines.

• Confirm authorizations for inpatients and commercial initiatives within established contractual deadlines.

• Oversee concurrent cases until resolution and perform initial and ongoing stay reviews.

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

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

• Implement evidence-based clinical review standards and escalate unsuccessful cases to the Physician Advisor or appeals process.

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

• Work in partnership with case managers, clinical social workers, physicians, and care teams on discharge planning and utilization management.

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

• Provide education to physicians and healthcare teams on utilization review and compliance protocols.

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

• Offer guidance and feedback to Utilization Managers and healthcare providers.

• Actively screen and evaluate high-risk, potentially readmitted patients, and those admitted through the emergency department.

• Coordinate community referrals and post-discharge arrangements to avert unnecessary admissions.

• Engage in hospital committees and initiatives focused on quality and performance improvement.

⛳️ 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 essential.

• 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 hire.

• Proficiency in basic computer skills is necessary.

• Ability to become skilled in navigating and interpreting an electronic health record is essential.

• Capability to function effectively in a self-directed environment and manage multiple tasks is required.

• Strong problem-solving skills for addressing complex issues on a daily basis.

• Exceptional written and verbal communication skills are critical.

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

🏝️ Benefits

• Relocation Assistance (subject to eligibility).

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

• Access to a health system with over 6,000 registered nurses.

• Involvement in hospital committees and quality/performance improvement initiatives.