Utilization Manager-Duke Raleigh
Company: Duke Health
Posted on: November 25, 2022
Duke Raleigh Hospital Duke Raleigh Hospital offers the latest in
care and technology in a patient-friendly setting. It has been an
important part of Duke Health since 1998 and has served Wake County
for more than 35 years, employing more than 2,000 teammembers. The
hospital provides 186 inpatient beds and a comprehensive array of
services, including the Duke Raleigh Cancer Center, Duke Raleigh
Orthopedic and Spine Center, cardiovascular services, neurosciences
including the Duke Raleigh Skull Base and Cerebrovascular Center,
advanced digestive care, disease management and prevention, wound
healing, outpatient imaging, intensive and progressive care, pain
clinic, same-day surgery, emergency department and community
outreach and education programs. U.S.News & World Report ranked
Duke Raleigh Hospital as high performing in orthopaedics and five
adult procedures/conditions: chronic obstructive pulmonary disease
(COPD), heart failure, kidney failure, lung cancer surgery, and
stroke.Duke Nursing Highlights: -
- Duke University Health System is designated as a Magnet
- Nurses from each hospital are consistently recognized each year
as North Carolina's Great 100 Nurses.
- Duke University Health System was awarded the American Board of
Nursing Specialties Award for Nursing Certification Advocacy for
being strong advocates of specialty nursing certification.
- Duke University Health System has 6000 + registered nurses
- Quality of Life: Living in the Triangle!
- Relocation Assistance (based on eligibility) -Occ
SummaryAssesses for accuracy in the assignment of patient class
(status) to reflect congruence with clinical condition, physician
intent, and utilization review outcomes with current rules and
regulatory requirements. Supports the medical chart audit process
by ensuring accurate, timely, and informative clinical review
documentation that supports the medical necessity/level of care.
Supports denials management by documenting activities related to
denials adjudication according to departmental guidelines and
actively works to overturn threatened denial activities. Complies
with current rules and regulatory requirements pertaining to
utilization management. Initiates actions to obtain appropriate
determinations. Collaborates with members of the healthcare team to
address, understand, and mitigate excess/avoidable days. Serves as
primary source of consultation for issues related to patient class
(status) determination.Work Performed
- Validates authorization for all bedded patients and commercial
initiatives. payer authorization within the contractual timeframe
at time of presentation, every third day or as needed (e.g. ED,
Direct Admit, Transfers).
- Manage concurrent cases to resolution care that may impact
payer approval to authorize care as medically necessary.
- Conducts initial review and continued stay reviews as
designated in UM plan.
- Reviews records for medical necessity and collaborates with
physician (s) and members of the care team to validate
- Establishes and communicates estimated LOS and expected
discharge date using GMLOS.
- Utilizes an evidenced-based clinical review screening criteria
as a guide to support medical necessity determinations and refers
cases with failed criteria to the Physician Advisor or appeals as
necessary in accordance with the UM plan.
- Facilitates mitigation of denials and peer to peer
- Collaborates with CM, CSW, Physicians, and Care Team to enhance
communication related to discharge planning and utilization
- Ongoing collaboration with Case Manager to ensure that
patient's condition meets medical necessity criteria and
communicate changes that could affect the discharge plan of
- Confirms that orders reflect the patient's billing patient
status in accordance with the UM plan. Partners with internal
Physician Advisors, as well as compliance and revenue cycle
partners, within the health system to a safeguard processes and
- Provides formal and informal education to physicians and the
healthcare team to improve processes and outcomes related to
utilization review and compliance with utilization management
- Gives feedback as requested to enhance negotiations with
- Develops and maintains positive relationships with customers
internal and external to Duke Health System.
- Maintains effective communication with health care team members
related to care coordination and utilization management.
- Contributes to a positive working environment and performs
other duties as assigned/directed to enhance the overall efforts
for the organization.
- Actively participates in a hospital committee.
- Works collaboratively with physicians, staff and service line
leadership on quality and performance improvement activities
related to optimal utilization of resources, efficient delivery of
high quality care, patient flow, capacity management and other
clinical cost reduction Utilization Manager Medical Chart Auditor
Completes retrospective medical necessity reviews for compliance
with regulatory or payor-specific guidelines for all short-stay
Medicare inpatients and outpatients (DUH), all observation
encounters, all combined/segmental billing encounter questions, and
any encounter sent to the UM MCA from PRMO for patient
status/post-bill medical necessity denials/coding questions.
Reviews and, when appropriate, completes as written appeal for
post-bill regulatory agency and Medicare advantage medical
- Provides education and feedback to the Utilization Managers and
Providers. ED UM/CM Proactive CM screening and assessment for
high-risk, potential readmits, and admitted patient
- Collaborate with ED treatment team to prevent inappropriate
admissions by facilitating community referrals and making post-dc
arrangements, as appropriate. Works collaboratively with inpatient
case management to support transitions from ED to inpatient. -Work
Hours4/10 hour shift with every other weekend -Knowledge, Skills
- Basic computer proficiency required
- Ability to become proficient in the navigation and
interpretation of an electronic health record.
- Work effectively in a self-directed role, multi-task, capable
of daily problem-solving complex issues.
- Excellent written and verbal skills
- Basic proficiency in the use of Microsoft Word, Power Point and
Excel -Level CharacteristicsN/A -Minimum Qualifications
-EducationBSN requiredExperienceMinimum of three years recent acute
clinical practice or related health care experience.Degrees,
Licensures, CertificationsRequires Case Management Certification
(ACM, CCM or ANCC) within 2 years of hire. BSN required and must
have current or compact RN licensure in state of NC. BLS
certification required. -Job Code: 00005279 UTILIZATION MANAGER
Job Level: G1 -Duke is an Affirmative Action/Equal Opportunity
Employer committed to providing employment opportunity without
regard to an individual's age, color, disability, gender, gender
expression, gender identity, genetic information, national origin,
race, religion, sex, sexual orientation, or veteran status. -Duke
aspires to create a community built on collaboration, innovation,
creativity, and belonging. Our collective success depends on the
robust exchange of ideas-an exchange that is best when the rich
diversity of our perspectives, backgrounds, and experiences
flourishes. To achieve this exchange, it is essential that all
members of the community feel secure and welcome, that the
contributions of all individuals are respected, and that all voices
are heard. All members of our community have a responsibility to
uphold these values. -Essential Physical Job Functions: Certain
jobs at Duke University and Duke University Health System may
include essential job functions that require specific physical
and/or mental abilities. Additional information and provision for
requests for reasonable accommodation will be provided by each
hiring department. -
Keywords: Duke Health, Cary , Utilization Manager-Duke Raleigh, Executive , Cary, North Carolina
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