Utilization Manager

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

📋 Description

• Evaluate the precision of patient classification/status assignments based on clinical conditions, physician intentions, outcomes of utilization reviews, and regulatory standards.

• Confirm payer authorizations for hospitalized patients and commercial initiatives within specified contractual timelines.

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

• Analyze records for medical necessity and work alongside physicians and care teams.

• Determine and communicate estimated lengths of stay and anticipated discharge dates utilizing GMLOS.

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

• Assist in denial mitigation and facilitate peer-to-peer discussions.

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

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

• Educate physicians and healthcare teams regarding utilization review processes and compliance requirements.

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

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

• Proactively screen and assess high-risk emergency department patients who may be at risk for readmission.

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

• Engage in hospital committees and activities aimed at quality and performance improvement.

⛳️ Requirements

• BSN is mandatory.

• A minimum of three years of recent acute clinical practice or relevant healthcare experience is required.

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

• BLS certification is a requirement.

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

• Basic computer skills are essential.

• Ability to proficiently navigate and interpret an electronic health record.

• Capability to work efficiently in a self-directed manner and handle multiple tasks.

• Daily engagement in problem-solving complex issues.

• Exceptional written and verbal communication skills are required.

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

🏝️ Benefits

• Relocation Assistance (subject to eligibility).

• Magnet-designated healthcare system.

• Opportunities for recognition through North Carolina's Great 100 Nurses.

• Advocacy for professional nursing certification.

• A collaborative, innovative, and inclusive work environment.