Duke Regional Hospital has served Durham, Orange, Person, Granville and Alamance counties and the surrounding communities for nearly 40 years. With more than 1,900 employees, its focus is on providing outstanding medical care with compassionate, personalized service in a comfortable community hospital setting. Duke Regional Hospital has 369 inpatient beds and offers a comprehensive range of medical, surgical and diagnostic services, including orthopedics, weight-loss surgery, women's services, and heart and vascular services, and also offers care at the Duke Rehabilitation Institute and Davis Ambulatory Surgical Center. In fiscal year 2018, Duke Regional Hospital admitted 16,299 patients and had 165,953 outpatient visits in fiscal year 2017.
U.S. News & World Report ranked Duke Regional Hospital as #10 in North Carolina and #4 in the Raleigh-Durham area for 2018-19.
Duke Nursing Highlights:
Duke University Health System is designated as a Magnet(r) organization
Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses.
Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.
Duke University Health System has 6000 + registered nurses
Quality of Life: Living in the Triangle!
12h shifts 9a-930p, and every third weekend.
Dual role working in both Utilization Management and Case Management
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.
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.
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
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.
Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas--an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
As a world-class academic and health care system, Duke Health strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.
What Information Do We Collect?
When you visit our website you may provide us with two types of information: personal information you knowingly choose to disclose that is collected on an individual basis and website use information collected on an aggregate basis as you and others browse our website.
Personal Information You Choose to Provide
We may request that you voluntarily supply us with personal information, including your email address, postal address, home or work telephone number and other personal information for such purposes as correspondence, placing an order, requesting an estimate, or participating in online surveys.
If you choose to correspond with us through email, we may retain the content of your email messages together with your email address and our responses. We provide the same protections for these electronic communications that we employ in the maintenance of information received by mail and telephone.
Website Use Information
Similar to other websites, our site may utilize a standard technology called "cookies" (see explanation below, "What Are Cookies?") and web server logs to collect information about how our website is used. Information gathered through cookies and server logs may include the date and time of visits, the pages viewed, time spent at our website, and the sites visited just before and just after ours. This information is collected on an aggregate basis. None of this information is associated with you as an individual.
How Do We Use the Information That You Provide to Us?
Broadly speaking, we use personal information for purposes of administering our business activities, providing service and support and making available other products and services to our customers and prospective customers. Occasionally, we may also use the information we collect to notify you about important changes to our website, new services and special offers we think you will find valuable. The lists used to send you product and service offers are developed and managed under our traditional standards designed to safeguard the security and privacy of all personal information provided by our users. You may at any time to notify us of your desire not to receive these offers.
What Are Cookies?
Cookies are a feature of web browser software that allows web servers to recognize the computer used to access a website. Cookies are small pieces of data that are stored by a user's web browser on the user's hard drive. Cookies can remember what information a user accesses on one web page to simplify subsequent interactions with that website by the same user or to use the information to streamline the user's transactions on related web pages. This makes it easier for a user to move from web page to web page and to complete commercial transactions over the Internet. Cookies should make your online experience easier and more personalized.
How Do We Use Information Collected From Cookies?
We use website browser software tools such as cookies and web server logs to gather information about our website users' browsing activities, in order to constantly improve our website and better serve our users. This information assists us to design and arrange our web pages in the most user-friendly manner and to continually improve our website to better meet the needs of our users and prospective users.
Cookies help us collect important business and technical statistics. The information in the cookies lets us trace the paths followed by users to our website as they move from one page to another. Web server logs allow us to count how many people visit our website and evaluate our website's visitor capacity. We do not use these technologies to capture your individual email address or any personally identifying information about you.
Notice of New Services and Changes
Occasionally, we may use the information we collect to notify you about important changes to our website, new services and special offers we think you will find valuable. As a user of our website, you will be given the opportunity to notify us of your desire not to receive these offers by clicking on a response box when you receive such an offer or by sending us an email request.
How Do We Secure Information Transmissions?
When you send confidential personal information to us on our website, a secure server software which we have licensed encrypts all information you input before it is sent to us. The information is scrambled en route and decoded once it reaches our website.
Other email that you may send to us may not be secure unless we advise you that security measures will be in place prior to your transmitting the information. For that reason, we ask that you do not send confidential information such as Social Security, credit card, or account numbers to us through an unsecured email.
How Do We Protect Your Information?
Information Security -- We utilize encryption/security software to safeguard the confidentiality of personal information we collect from unauthorized access or disclosure and accidental loss, alteration or destruction.
Evaluation of Information Protection Practices -- Periodically, our operations and business practices are reviewed for compliance with organization policies and procedures governing the security, confidentiality and quality of our information.
Employee Access, Training and Expectations -- Our organization values, ethical standards, policies and practices are committed to the protection of user information. In general, our business practices limit employee access to confidential information, and limit the use and disclosure of such information to authorized persons, processes and transactions.
How Can You Access and Correct Your Information?
You may request access to all your personally identifiable information that we collect online and maintain in our database by emailing us using the contact form provided to you within the site structure of our website.
Do We Disclose Information to Outside Parties?
What About Legally Compelled Disclosure of Information?
We may disclose information when legally compelled to do so, in other words, when we, in good faith, believe that the law requires it or for the protection of our legal rights.
Permission to Use of Materials
The right to download and store or output the materials in our website is granted for the user's personal use only, and materials may not be reproduced in any edited form. Any other reproduction, transmission, performance, display or editing of these materials by any means mechanical or electronic without our express written permission is strictly prohibited. Users wishing to obtain permission to reprint or reproduce any materials appearing on this site may contact us directly.
We are grateful for your donation and support of our organization. If you have made an error in making your donation or change your mind about contributing to our organization please contact us. Refunds are returned using the original method of payment. If you made your donation by credit card, your refund will be credited to that same credit card.
Automated Recurring Donation Cancellation
Ongoing support is important to enabling projects to continue their work, so we encourage donors to continue to contribute to projects over time. But if you must cancel your recurring donation, please notify us.