UTILIZATION MANAGER

  • Requisition Number: 100087302
  • Department: DUKE HOSPITAL
  • Location: Durham
  • Type of Position: Regular
  • Shift: First/Day
  • Apply

Four 10hr shifts and every other weekend.

Occupational 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.

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
  • 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 supportmedical necessity determinations.
  • Refers cases with failed criteria to Physician Advisor and appeals asnecessary.
  • 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