Utilization Manager – Behavioral Health
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Job Description
Duke Health utilization manager overseeing behavioral-health medical necessity, authorization, and denial reviews. Supporting patient flow, discharge planning, audits, and quality improvement.
Responsibilities:
- Assess accuracy of patient class/status assignments based on clinical condition, physician intent, utilization review outcomes, rules, and regulatory requirements
- Support medical chart audits through accurate, timely, and informative clinical review documentation
- Support denials management and work to overturn threatened denials
- Validate authorizations 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
- Establish and communicate estimated length of stay and expected discharge dates using GMLOS
- Apply evidence-based clinical review screening criteria and refer failed cases to Physician Advisors or appeals
- 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
- Educate physicians and healthcare teams on utilization review and compliance processes
- Provide feedback to improve payer negotiations
- Maintain relationships and communication with internal and external customers
- Participate in a hospital committee
- Collaborate on quality and performance improvement, resource utilization, patient flow, capacity management, and clinical cost reduction
- Complete retrospective medical necessity reviews and written appeals for regulatory agency and Medicare Advantage audits
- Provide education and feedback to Utilization Managers and providers
- Proactively screen and assess high-risk, potential readmission, and admitted patient encounters in the emergency department
- Facilitate community referrals, post-discharge arrangements, and transitions from the ED 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 North Carolina required
- 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 work 40 hours and every other weekend
Benefits:
- Relocation Assistance (based on eligibility)
- Duke University Health System is designated as a Magnet organization
- Opportunity to work with a health system with 6,000+ registered nurses
- Equal employment opportunity and commitment to diversity, inclusion, collaboration, innovation, creativity, and belonging
- Reasonable accommodation support available
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