Utilization Manager

Job not on LinkedIn

🔥 2 minutes 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 patient class/status accuracy against clinical condition, physician intent, utilization review outcomes, rules and regulatory requirements • 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 criteria and refer failed cases to the Physician Advisor or appeals process • 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 • Complete retrospective medical necessity reviews and written appeals for 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 • Facilitate community referrals and post-discharge arrangements to prevent inappropriate admissions • Participate in hospital committees and quality/performance improvement activities

🎯 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 required • BLS certification required • Case Management Certification (ACM, CCM or ANCC) required 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

🏖️ Benefits

• Relocation Assistance (based on eligibility) • Duke University Health System is designated as a Magnet organization • Access to a health system with 6,000+ registered nurses • Participation in hospital committees and quality/performance improvement activities