Utilization Manager

Overview

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.

About Duke University Hospital

Pursue your passion for caring with Duke University Hospital in Durham, North Carolina, which is consistently ranked among the best in the United States. The largest of the four Duke Health hospitals with 1062 patient beds, it features comprehensive diagnostic and therapeutic facilities, including a regional emergency/trauma center, an endo-surgery center, and more.

Duke Nursing Highlights:

• 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 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 Summary

Assesses 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. Communicate and coordinate with all provider(s) and member(s) of the care team as needed to minimize fragmented care and foster appropriate utilization of services.

This may include, working collaboratively with inpatient case management to support post-acute placement clinical referral accuracy and referral.

Work Performed

Validates authorization for all bedded patients. Validates commercial 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 information.

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 conversations. Collaborates with CM, CSW, Physicians, and Care Team to enhance communication related to discharge planning and utilization management.

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 care. 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 expected outcomes.

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 plan. Provides feedback as requested to…