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 with accurate, timely clinical review documentation supporting medical necessity and level of care • Document denial adjudication activities and actively work to overturn threatened denials • Validate authorization for bedded patients and commercial initiatives within contractual timeframes • Manage concurrent cases through resolution affecting payer approval of medically necessary care • 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 criteria to the Physician Advisor or appeals process • Facilitate denial mitigation and peer-to-peer conversations • Collaborate with case managers, 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 • Provide education to physicians and healthcare teams on utilization review and compliance • Maintain relationships with internal and external customers and effective care coordination communication • Participate in a hospital committee • Support quality and performance improvement activities related to resource utilization, care delivery, patient flow, capacity management, and clinical cost reduction • Complete retrospective medical necessity reviews and written appeals for applicable post-bill audits and denials • Provide education and feedback to Utilization Managers and providers • Proactively screen and assess high-risk, potential readmit, and admitted patient encounters in the emergency department • Collaborate with ED treatment teams to prevent inappropriate admissions and facilitate community referrals and post-discharge arrangements • Support transitions from the ED to inpatient care

🎯 Requirements

• BSN required • Minimum of three years recent acute clinical practice or related health care experience • Requires Case Management Certification (ACM, CCM or ANCC) within 2 years of hire • Must have current or compact RN licensure in state of NC • BLS certification required • 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 • Daily problem-solving of complex issues • Excellent written and verbal skills • Basic proficiency in Microsoft Word, PowerPoint, and Excel

🏖️ Benefits

• Relocation Assistance (based on eligibility) • Duke University Health System is designated as a Magnet organization • Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses • Duke University Health System has 6000 + registered nurses • Equal employment opportunity and nondiscrimination commitment • Reasonable accommodation information and provisions available