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

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Demonstrates expertise in clinical review, utilization management, and denial management, with a strong focus on medical necessity and compliance. Proficient in collaborating with healthcare teams and physicians to ensure optimal patient care and adherence to regulatory standards.

Highest-signal resume keywords

Clinical ReviewUtilization ManagementDenial ManagementCase Management CertificationRN Licensure

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity ReviewUtilization ReviewConcurrent Case ManagementEvidence-Based Screening CriteriaDischarge Planning

Soft Skills

Excellent Written SkillsExcellent Verbal SkillsProblem SolvingSelf-Directed Work

Tools & Technologies

Electronic Health RecordMicrosoft WordMicrosoft PowerPointMicrosoft Excel

Certifications & Qualifications

BSNBLS CertificationCase Management Certification

Industry Keywords

Patient Class AssignmentDenials AdjudicationQuality ImprovementHealthcare ComplianceAcute Clinical Practice

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 through accurate, timely clinical review documentation supporting medical necessity and level of care
Support denials management and document denials adjudication activities
Validate authorization for bedded patients and commercial initiatives within contractual timeframes
Manage concurrent cases through resolution of care issues affecting payer approval
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 cases to the Physician Advisor or appeals process
Facilitate denial mitigation and peer-to-peer conversations
Collaborate on discharge planning, utilization management, care coordination and transitions from the emergency department
Confirm orders reflect billing patient status
Provide education to physicians and healthcare teams on utilization review and compliance
Participate in hospital committees and quality and performance improvement activities
Complete retrospective medical necessity reviews and written appeals for applicable audits and denials

Requirements

What you’ll need

BSN required
Minimum of three years recent acute clinical practice or related health care experience
Current or compact RN licensure in the state of North Carolina
BLS certification required
Case Management Certification (ACM, CCM or ANCC) required within 2 years of hire
Basic computer proficiency
Ability to become proficient in navigation and interpretation of an electronic health record
Ability to work effectively in a self-directed role and multitask
Ability to solve complex issues daily
Excellent written and verbal skills
Basic proficiency in Microsoft Word, PowerPoint and Excel

Benefits

Comp & perks

Relocation Assistance (based on eligibility)
Magnet organization affiliation and nursing certification advocacy support
Equal opportunity employment
Reasonable accommodation support