Utilization Manager PRN 2 shifts of 8 hours a month
Work Arrangement:
Requisition Number: 273431
Regular or Temporary: Regular
Location:
Durham, NC, US, 27710
Personnel Area: DUKE REGIONAL HOSPITAL
Date: Sep 4, 2026
At Duke Health, we're driven by a commitment to compassionate care that
changes the lives of patients, their loved ones, and the greater community. No
matter where your talents lie, join us and discover how we can advance health
together.
About Duke Regional Hospital
Pursue your passion for caring with Duke Regional Hospital in Durham, North
Carolina. With 388 beds it is the second largest of Duke Health's four
hospitals and offers a comprehensive range ofmedical, surgical, and diagnostic
services, including orthopedics, weight-loss surgery, women's services, and
heart and vascular services.
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!
Relocation Assistance (based on eligibility)
2 shifts of 8 hours a month
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 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.
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
Level Characteristics
N/A
Minimum Qualifications
Education
BSN required
Experience
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 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 (including pregnancy and pregnancy related conditions),
sexual orientation or military 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.
Nearest Major Market: Durham
Nearest Secondary Market: Raleigh
