Utilization Manager, Duke Raleigh Hospital
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.
- 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
- Partner with Revenue Cycle team to support resolution of retrospective denials.
- Coordination of review with third party reviewers.
- Manage retrospective review process.
- 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 using GMLOS.
- Utilizes InterQual Level of Care Criteria as a guide to support medical necessity determinations.
- Refers cases with failed criteria to Physician Advisor and appeals as necessary.
- Collaborates with CM, SW, 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 level of care utilizing established criteria.
- Partners with internal and external Physician Advisors, as well as Compliance and with Revenue Cycle partners, within the health system to provide 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 enhance negotiations with payors.
- 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 initiatives.
Knowledge Skills and Abilities
- Basic computer proficiency required
- Ability to become proficient in the navigation and interpretation of an electronic health record
- Ability to work effectively in a self-directed role
- Ability to 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 Characteristics N/A
Duke Entity DUKE RALEIGH HOSPITAL
Job Family Level G1
Full Time / Part Time PART TIME / PRN
Regular / Temporary Regular
Duke University 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.
Minimum of three years recent acute clinical practice or related health care experience.
Degrees, Licensures, Certifications
Must have current or compact RN licensure in the state of North Carolina; ACM, CCM or other certification applicable to utilization management within 3 years of hire or by December 31, 2017 for current employee. BLS certification required.