Utilization Manager

Duke Careers

. Assess accuracy of patient class/status assignments against clinical condition, physician intent, utilization review outcomes, rules, and regulatory requirements .

Posted 9/15/2026full-timeRemote • North Carolina • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in Utilization Management, including conducting medical necessity reviews, managing concurrent cases, and collaborating with healthcare teams to ensure compliance and effective care coordination. Proficient in applying evidence-based clinical review criteria and navigating electronic health records to support patient care and resource utilization.

Highest-signal resume keywords

Utilization ManagementCase Management Certification (ACM, CCM, ANCC)BSNRN Licensure in NCMedical Necessity Review

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Review DocumentationDenial AdjudicationAuthorization ValidationEvidence-Based Clinical ReviewPatient Flow ManagementQuality Improvement ActivitiesRetrospective Medical Necessity ReviewsProblem-SolvingElectronic Health Record NavigationMultitasking

Soft Skills

Excellent Written SkillsExcellent Verbal SkillsEffective CommunicationRelationship ManagementSelf-Directed Work

Tools & Technologies

Microsoft WordMicrosoft PowerPointMicrosoft Excel

Certifications & Qualifications

BLS CertificationCase Management Certification (ACM, CCM, ANCC)

Industry Keywords

Patient Class/Status AssignmentsUtilization ReviewClinical Cost ReductionCare CoordinationDischarge Planning

About the role

Key responsibilities & impact

Assess accuracy of patient class/status assignments against clinical condition, physician intent, utilization review outcomes, rules, and regulatory requirements
Support medical chart audits with accurate, timely clinical review documentation supporting medical necessity and level of care
Document denial adjudication activities and actively work to overturn threatened denials
Validate authorization for bedded patients and commercial initiatives within contractual timeframes
Manage concurrent cases through resolution affecting payer approval of medically necessary care
Conduct initial and continued-stay reviews according to the utilization management plan
Review records for medical necessity and collaborate with physicians and care teams
Establish and communicate estimated length of stay and expected discharge date using GMLOS
Apply evidence-based clinical review screening criteria and refer failed criteria to the Physician Advisor or appeals process
Facilitate denial mitigation and peer-to-peer conversations
Collaborate with case managers, social workers, physicians, and care teams on discharge planning and utilization management
Confirm orders reflect billing patient status and partner with Physician Advisors, compliance, and revenue cycle teams
Provide education to physicians and healthcare teams on utilization review and compliance
Maintain relationships with internal and external customers and effective care coordination communication
Participate in a hospital committee
Support quality and performance improvement activities related to resource utilization, care delivery, patient flow, capacity management, and clinical cost reduction
Complete retrospective medical necessity reviews and written appeals for applicable post-bill audits and denials
Provide education and feedback to Utilization Managers and providers
Proactively screen and assess high-risk, potential readmit, and admitted patient encounters in the emergency department
Collaborate with ED treatment teams to prevent inappropriate admissions and facilitate community referrals and post-discharge arrangements
Support transitions from the ED to inpatient care

Requirements

What you’ll need

BSN required
Minimum of three years recent acute clinical practice or related health care experience
Requires Case Management Certification (ACM, CCM or ANCC) within 2 years of hire
Must have current or compact RN licensure in state of NC
BLS certification required
Basic computer proficiency
Ability to become proficient in navigating and interpreting an electronic health record
Ability to work effectively in a self-directed role and multitask
Daily problem-solving of complex issues
Excellent written and verbal skills
Basic proficiency in Microsoft Word, PowerPoint, and Excel

Benefits

Comp & perks

Relocation Assistance (based on eligibility)
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 has 6000 + registered nurses
Equal employment opportunity and nondiscrimination commitment
Reasonable accommodation information and provisions available