Utilization Manager – Behavioral Health

Job not on LinkedIn

🔥 14 hours ago

🌲 North Carolina – Remote

🌲 North Carolina – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

👻 Ghost score 13%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Duke Careers

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1924

💼 Consulting

🏥 Healthcare

📚 Education

Consulting • Healthcare • Education

Duke Careers is a platform connected to Duke University's rich legacy, established in 1924. It aims to celebrate the centennial of Duke University while providing resources, stories, and interviews that reflect the university's history, current achievements, and future aspirations. A key focus of Duke Careers is to engage with alumni and the community, showcasing the transformative impact of education and leadership within the university.

📋 Description

• Assess accuracy of patient class/status assignments based on clinical condition, physician intent, utilization review outcomes, rules, and regulatory requirements • Support medical chart audits through accurate, timely, and informative clinical review documentation • Support denials management and work to overturn threatened denials • Validate authorizations for bedded patients and commercial initiatives within contractual timeframes • Manage concurrent cases through resolution and conduct initial and continued-stay reviews • Review records for medical necessity and collaborate with physicians and care teams • Establish and communicate estimated length of stay and expected discharge dates using GMLOS • Apply evidence-based clinical review screening criteria and refer failed cases to Physician Advisors or appeals • Facilitate denial mitigation and peer-to-peer conversations • Collaborate with case managers, clinical social workers, physicians, and care teams on discharge planning and utilization management • Confirm orders reflect billing patient status and partner with Physician Advisors, compliance, and revenue cycle teams • Educate physicians and healthcare teams on utilization review and compliance processes • Provide feedback to improve payer negotiations • Maintain relationships and communication with internal and external customers • Participate in a hospital committee • Collaborate on quality and performance improvement, resource utilization, patient flow, capacity management, and clinical cost reduction • Complete retrospective medical necessity reviews and written appeals for regulatory agency and Medicare Advantage audits • Provide education and feedback to Utilization Managers and providers • Proactively screen and assess high-risk, potential readmission, and admitted patient encounters in the emergency department • Facilitate community referrals, post-discharge arrangements, and transitions from the ED to inpatient care

🎯 Requirements

• BSN required • Minimum of three years recent acute clinical practice or related health care experience • Current or compact RN licensure in North Carolina required • BLS certification required • Requires Case Management Certification (ACM, CCM or ANCC) within 2 years of hire • Basic computer proficiency • Ability to become proficient in navigating and interpreting an electronic health record • Ability to work effectively in a self-directed role and multitask • Ability to solve complex issues daily • Excellent written and verbal skills • Basic proficiency in Microsoft Word, PowerPoint, and Excel • Ability to work 40 hours and every other weekend

🏖️ Benefits

• Relocation Assistance (based on eligibility) • Duke University Health System is designated as a Magnet organization • Opportunity to work with a health system with 6,000+ registered nurses • Equal employment opportunity and commitment to diversity, inclusion, collaboration, innovation, creativity, and belonging • Reasonable accommodation support available