Utilization Manager Weekend

Utilization Manager 10hr Every Other Weekend

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At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

4‑hour shift (10 hours total) every other weekend.

• Assess 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.
• Support the medical chart audit process by ensuring accurate, timely, and informative clinical review documentation that supports the medical necessity/level of care.
• Support denials management by documenting activities related to denials adjudication according to departmental guidelines and actively work to overturn threatened denial activities.
• Comply with current rules and regulatory requirements pertaining to utilization management.
• Initiate actions to obtain appropriate determinations.
• Collaborate with members of the healthcare team to address, understand, and mitigate excess/avoidable days.
• Serve as primary source of consultation for issues related to patient class (status) determination.
• Validate authorization for all bedded patients and commercial initiatives.
• Manage concurrent cases to resolution care that may impact payer approval to authorize care as medically necessary.
• Conduct initial review and continued stay reviews as designated in UM plan.
• Review records for medical necessity and collaborate with physicians and members of the care team to validate information.
• Establish estimated LOS and expected discharge date using GMLOS.
• Use evidence‑based clinical review screening criteria to support medical necessity determinations and refer cases with failed criteria to Physician Advisor or appeals as necessary.
• Facilitate mitigation of denials and peer‑to‑peer conversations.
• Collaborate with CM, CSW, physicians, and care team to enhance communication related to discharge planning and utilization management.
• Continue collaboration with case manager to ensure patient condition meets medical necessity criteria and communicate changes that could affect the discharge plan.
• Confirm orders reflect patient billing status in accordance with UM plan.
• Partner with internal physician advisors, compliance and revenue cycle partners to safeguard processes and outcomes.
• Provide formal and informal education to physicians and healthcare team to improve processes and outcomes related to utilization review and compliance.
• Provide feedback as requested to enhance negotiations with payors.
• Develop and maintain positive relationships with internal and external customers.
• Maintain effective communication with health care team members related to care coordination and utilization management.
• Contribute to a positive working environment and perform other duties as assigned to enhance overall organization efforts.
• Actively participate in a hospital committee.
• Collaborate 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.
• Complete retrospective medical necessity reviews for compliance with regulatory or payor‑specific guidelines for all short‑stay Medicare inpatients and outpatients, observation encounters, and other UM cases.
• Provide education and feedback to the Utilization Managers and Providers and support EMD UM/CM proactive CM screening.
• Collaborate with ED treatment team to prevent inappropriate admissions by facilitating community referrals.
• Work collaboratively with inpatient case management to support transitions from ED to inpatient.

• 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…