Utilization Manager-Duke Raleigh ED Duke Raleigh UM 4/10s every other weekend
Duke University Health System
Location: Raleigh, North Carolina
Internal Number: 123471
Duke Raleigh Hospital offers the latest in care and technology in a patient-friendly setting. It has been an important part of Duke Health since 1998 and has served Wake County for more than 35 years, employing more than 2,000 team members. The hospital provides 186 inpatient beds and a comprehensive array of services, including the Duke Raleigh Cancer Center, Duke Raleigh Orthopedic and Spine Center, cardiovascular services, neurosciences including the Duke Raleigh Skull Base and Cerebrovascular Center, advanced digestive care, disease management and prevention, wound healing, outpatient imaging, intensive and progressive care, pain clinic, same-day surgery, emergency department and community outreach and education programs
U.S. News & World Report ranked Duke Raleigh Hospital as high performing in orthopaedics and two adult procedures/conditions: Chronic Obstructive Pulmonary Disease (COPD) and lung cancer surgery. #DukeRaleighJobs
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!
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 and commercial initiatives. 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.
Gives 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 Utilization Manager Medical Chart Auditor Completes retrospective medical necessity reviews for compliance with regulatory or payor-specific guidelines for all short-stay Medicare inpatients and outpatients (DUH), all observation encounters, all combined/segmental billing encounter questions, and any encounter sent to the UM MCA from PRMO for patient status/post-bill medical necessity denials/coding questions. Reviews and, when appropriate, completes as written appeal for post-bill regulatory agency and Medicare advantage medical necessity audits.
Provides education and feedback to the Utilization Managers and Providers. ED UM/CM Proactive CM screening and assessment for high-risk, potential readmits, and admitted patient encounters.
Collaborate with ED treatment team to prevent inappropriate admissions by facilitating community referrals and making post-dc arrangements, as appropriate. Works collaboratively with inpatient case management to support transitions from ED to inpatient.
4/10's every other weekend
Knowledge, Skills and Abilities
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 daily problem-solving complex issues.
Excellent written and verbal skills
Basic proficiency in the use of Microsoft Word, Power Point and Excel
Minimum of three years recent acute clinical practice or related health care experience.
Degrees, Licensures, Certifications
Requires Case Management Certification (ACM, CCM or ANCC) within 2 years of hire. BSN required and must have current or compact RN licensure in state of NC. BLS certification required.
Duke 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.
As a world-class academic and health care system, Duke Health strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.