Utilization Manager

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

📋 Description

• Evaluate the correctness of patient classification/status assignments based on clinical conditions, physician intent, utilization review results, regulations, and compliance requirements.

• Assist in medical chart audits by providing accurate and timely clinical review documentation that substantiates medical necessity and levels of care.

• Aid in managing denials and strive to reverse potential denials.

• Confirm payer authorization for hospitalized patients and commercial initiatives within specified contractual timeframes.

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

• Analyze records for medical necessity and work with physicians and care teams to validate the information.

• Determine and communicate projected length of stay and anticipated discharge dates using GMLOS.

• Utilize evidence-based clinical review criteria and escalate instances of failed criteria to the Physician Advisor or the appeals process.

• Facilitate discussions aimed at denial mitigation and peer-to-peer interactions.

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

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

• Educate physicians and healthcare teams about utilization review and compliance protocols.

• Engage in negotiations with payors by providing necessary feedback.

• Maintain strong relationships with both internal and external Duke Health stakeholders.

• 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 medical necessity reviews for designated Medicare, observation, billing, and denial cases.

• Draft written appeals for post-bill regulatory agency and Medicare Advantage medical necessity audits when necessary.

• Offer education and constructive feedback to Utilization Managers and providers.

• Proactively identify and assess high-risk, potential readmissions, and admitted patient encounters in the emergency department.

• Work with ED treatment teams to avert inappropriate admissions and promote community referrals and post-discharge arrangements.

• Support transitions from the emergency department to inpatient care.

⛳️ Requirements

• BSN is required.

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

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

• BLS certification is required.

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

• Basic proficiency in computer skills is necessary.

• Capability to navigate and interpret an electronic health record effectively.

• Ability to excel in a self-directed role and manage multiple tasks simultaneously.

• Skill in resolving complex issues on a daily basis.

• Exceptional written and verbal communication skills are essential.

• Basic knowledge of Microsoft Word, PowerPoint, and Excel is required.

• Ability to collaborate effectively with physicians, staff, and healthcare team members.

🏝️ Benefits

• Relocation Assistance (dependent on eligibility).