Utilization Manager

Job not on LinkedIn

🕒 4 days 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.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

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 work to overturn threatened denials • Validate payer authorization 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 to validate information • Establish and communicate estimated length of stay and expected discharge dates using GMLOS • Apply evidence-based clinical review criteria and refer failed criteria 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 • Provide education to physicians and healthcare teams on utilization review and compliance • Participate in negotiations with payors by providing feedback • Maintain relationships with internal and external Duke Health customers • Participate in a hospital committee • Support quality and performance improvement involving resource utilization, care delivery, patient flow, capacity management, and clinical cost reduction • Complete retrospective medical necessity reviews for specified Medicare, observation, billing, and denial cases • Prepare written appeals for post-bill regulatory agency and Medicare Advantage medical necessity audits when appropriate • 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 emergency department 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 the state of North Carolina • 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 collaborate with physicians, staff, and healthcare team members

🏖️ Benefits

• Relocation Assistance (based on eligibility)