Health Utilization & Denials Specialist

Duke University; Mooresville (NC); On-site; USD 85,000 - 115,000; Full time

Benefits offered by this job

Relocation assistance

Job summary

Duke University Health System seeks a Utilization Manager/Medical Chart Auditor to support utilization review and ensure medical necessity across patient care episodes. The role collaborates with physicians, case managers and the care team to optimize patient flow, discharge planning and compliance with UM plans.

Applicants will have a BSN, at least three years of acute care experience, and must obtain Case Management Certification within two years.

Qualifications

• BSN required.
• Minimum of three years recent acute clinical practice or related health care experience.
• Case Management Certification (ACM, CCM or ANCC) within 2 years of hire.

Responsibilities

• Validate authorization for bedded patients and payer initiatives within contractual timeframes.
• Manage concurrent cases to resolution of care impacting payer approval.
• Conduct initial and continued stay reviews as designated in UM plan.
• Review medical records for medical necessity and collaborate with physicians and care team.
• Establish estimated LOS and discharge date using GMLOS.
• Educate physicians and care team to improve utilization management processes.

Skills

Computer proficiency

EHR navigation

Self-directed work

Written and verbal communication

Education

BSN degree

Tools

Microsoft Word

PowerPoint

Excel

Job description

Duke University Health System seeks a Utilization Manager/Medical Chart Auditor to support utilization review and ensure medical necessity across patient care episodes. The role collaborates with physicians, case managers and the care team to optimize patient flow, discharge planning and compliance with UM plans.

Applicants will have a BSN, at least three years of acute care experience, and must obtain Case Management Certification within two years.