Every other weekend 8 hours 5 days a week

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.