Utilization Manager – Behavioral Health

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

📋 Description

• Evaluate the precision of patient class/status assignments based on clinical conditions, physician intentions, utilization review results, regulations, and compliance requirements.

• Assist with medical chart audits by providing accurate, timely, and insightful clinical review documentation.

• Support the management of denials and work towards reversing potential denials.

• Confirm authorizations for hospitalized patients and commercial initiatives within agreed timelines.

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

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

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

• Implement evidence-based clinical review screening criteria and refer unsuccessful cases to Physician Advisors or appeals.

• Lead denial mitigation efforts and facilitate peer-to-peer discussions.

• 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 collaborate with Physician Advisors, compliance, and revenue cycle teams.

• Provide education to physicians and healthcare teams regarding utilization review and compliance procedures.

• Offer feedback to enhance payer negotiations.

• Maintain strong relationships and communication with both internal and external stakeholders.

• Participate in a hospital committee.

• Work together on quality and performance improvement initiatives, resource utilization, patient flow, capacity management, and clinical cost reduction.

• Conduct retrospective medical necessity reviews and write appeals for regulatory agency and Medicare Advantage audits.

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

• Proactively screen and evaluate high-risk patients, those at potential risk of readmission, and admitted patient encounters in the emergency department.

• Facilitate community referrals, post-discharge arrangements, and transitions from the emergency department to inpatient care.

⛳️ Requirements

• BSN is mandatory.

• At least 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 required.

• Must obtain Case Management Certification (ACM, CCM, or ANCC) within two years of hire.

• Basic computer skills are essential.

• Ability to become proficient in navigating and interpreting an electronic health record is required.

• Capability to work effectively in a self-directed role and manage multiple tasks simultaneously.

• Must be able to resolve complex issues on a daily basis.

• Strong written and verbal communication skills are needed.

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

• Availability to work 40 hours a week and every other weekend is necessary.

🏝️ Benefits

• Relocation Assistance (subject to eligibility).

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

• Opportunity to be part of a health system with over 6,000 registered nurses.

• Commitment to equal employment opportunities and fostering a culture of diversity, inclusion, collaboration, innovation, creativity, and belonging.

• Support for reasonable accommodation is available.