Utilization Manager

Job not on LinkedIn

🔥 13 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 against clinical condition, physician intent, utilization review outcomes, rules and regulatory requirements • Support medical chart audits through accurate, timely clinical review documentation supporting medical necessity and level of care • Support denials management and document denials adjudication activities • Validate authorization for bedded patients and commercial initiatives within contractual timeframes • Manage concurrent cases through resolution of care issues affecting payer approval • Conduct initial and continued-stay reviews according to the utilization management plan • Review records for medical necessity and collaborate with physicians and care teams • Establish and communicate estimated length of stay and expected discharge date using GMLOS • Apply evidence-based clinical review screening criteria and refer failed cases to the Physician Advisor or appeals process • Facilitate denial mitigation and peer-to-peer conversations • Collaborate on discharge planning, utilization management, care coordination and transitions from the emergency department • Confirm orders reflect billing patient status • Provide education to physicians and healthcare teams on utilization review and compliance • Participate in hospital committees and quality and performance improvement activities • Complete retrospective medical necessity reviews and written appeals for applicable audits and denials

🎯 Requirements

• BSN required • Minimum of three years recent acute clinical practice or related health care experience • Current or compact RN licensure in the state of North Carolina • BLS certification required • Case Management Certification (ACM, CCM or ANCC) required within 2 years of hire • Basic computer proficiency • Ability to become proficient in navigation and interpretation of 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

🏖️ Benefits

• Relocation Assistance (based on eligibility) • Magnet organization affiliation and nursing certification advocacy support • Equal opportunity employment • Reasonable accommodation support