Utilization Manager – Behavioral Health

Duke Careers

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

Posted 9/23/2026full-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 clinical review, utilization management, and denial mitigation while effectively collaborating with healthcare teams to ensure compliance and optimize patient care outcomes. Proficient in navigating electronic health records and conducting medical necessity reviews to support regulatory requirements.

Highest-signal resume keywords

BSNRN Licensure in North CarolinaCase Management Certification (ACM, CCM or ANCC)Clinical Review DocumentationUtilization Management

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewMedical Necessity ReviewDenial ManagementUtilization ReviewConcurrent Case ManagementEvidence-Based Screening CriteriaPatient Flow ManagementCapacity ManagementRegulatory ComplianceElectronic Health Record Navigation

Soft Skills

Excellent Written SkillsExcellent Verbal SkillsProblem-SolvingSelf-Directed WorkMultitasking

Tools & Technologies

Microsoft WordMicrosoft PowerPointMicrosoft Excel

Certifications & Qualifications

BLS CertificationCase Management Certification (ACM, CCM or ANCC)

Industry Keywords

Acute Clinical PracticePatient Class/Status AssignmentsPeer-to-Peer ConversationsQuality ImprovementHealthcare CompliancePayer NegotiationsCommunity ReferralsTransitions of CareEmergency Department EncountersMedicare Advantage Audits

About the role

Key responsibilities & impact

Assess accuracy of patient class/status assignments based on clinical condition, physician intent, utilization review outcomes, rules, and regulatory requirements
Support medical chart audits through accurate, timely, and informative clinical review documentation
Support denials management and work to overturn threatened denials
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 screening criteria and refer failed cases to Physician Advisors or appeals
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
Provide feedback to improve payer negotiations
Maintain relationships and communication with internal and external customers
Participate in a hospital committee
Collaborate on quality and performance improvement, resource utilization, patient flow, capacity management, and clinical cost reduction
Complete retrospective medical necessity reviews and written appeals for regulatory agency and Medicare Advantage audits
Provide education and feedback to Utilization Managers and providers
Proactively screen and assess high-risk, potential readmission, and admitted patient encounters in the emergency department
Facilitate community referrals, post-discharge arrangements, and 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
Current or compact RN licensure in North Carolina required
BLS certification required
Requires Case Management Certification (ACM, CCM or ANCC) 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
Ability to work 40 hours and every other weekend

Benefits

Comp & perks

Relocation Assistance (based on eligibility)
Duke University Health System is designated as a Magnet organization
Opportunity to work with a health system with 6,000+ registered nurses
Equal employment opportunity and commitment to diversity, inclusion, collaboration, innovation, creativity, and belonging
Reasonable accommodation support available