Duke University Health System (DUHS) Job Descriptions

UTILIZATION MANAGER

Job Title: UTILIZATION MANAGER
Job Code: 5279
FLSA: E
Job Level: G1
Revised Date: 07/01/2023
Supervisory Responsibility: No

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General Description of the Job Class

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.

Duties and Responsibilities of this Level

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 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.

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.

Required Qualifications at this Level

Education

BSN required

Experience

Minimum of three years recent acute clinical practice or related health care experience.

Degrees, Licensure, and/or Certification

Requires Case Management Certification (ACM, CCM or ANCC) within 3 years of hire.

BSN required and must have current or compact RN licensure in state of NC.

BLS certification required.

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.

Distinguishing Characteristics of this Level

N/A

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The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.

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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.

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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.