Utilization Manager

Duke Careers

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

Posted 10/8/2026full-timeRemote • North Carolina • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and Clinical Review, ensuring compliance with regulatory requirements while effectively collaborating with healthcare teams. Proficient in managing patient cases, conducting medical necessity reviews, and facilitating discharge planning.

Highest-signal resume keywords

Utilization ManagementClinical ReviewCase Management CertificationRN LicensureBLS Certification

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity ReviewDischarge PlanningConcurrent Case ManagementEvidence-Based Clinical ReviewElectronic Health Record Navigation

Soft Skills

Excellent Written SkillsExcellent Verbal SkillsProblem SolvingSelf-Directed WorkMultitasking

Tools & Technologies

Microsoft WordMicrosoft PowerPointMicrosoft Excel

Certifications & Qualifications

BSNRN LicensureBLS CertificationCase Management Certification

Industry Keywords

Clinical Condition AssessmentUtilization ReviewPeer-to-Peer ConversationsDenial MitigationQuality Improvement Activities

About the role

Key responsibilities & impact

Assess patient class/status accuracy against clinical condition, physician intent, utilization review outcomes, rules and regulatory requirements
Validate authorizations for bedded patients and commercial initiatives within contractual timeframes
Manage concurrent cases through resolution and conduct initial and continued-stay reviews
Review records for medical necessity and collaborate with physicians and care teams
Establish and communicate estimated length of stay and expected discharge dates using GMLOS
Apply evidence-based clinical review criteria and refer failed cases to the Physician Advisor or appeals process
Facilitate denial mitigation and peer-to-peer conversations
Collaborate with case managers, clinical 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
Educate physicians and healthcare teams on utilization review and compliance processes
Complete retrospective medical necessity reviews and written appeals for 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
Facilitate community referrals and post-discharge arrangements to prevent inappropriate admissions
Participate in hospital committees and quality/performance improvement activities

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 required
BLS certification required
Case Management Certification (ACM, CCM or ANCC) required within 2 years of hire
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
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)
Duke University Health System is designated as a Magnet organization
Access to a health system with 6,000+ registered nurses
Participation in hospital committees and quality/performance improvement activities