At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together. About Duke Regional Hospital Pursue your passion for caring with Duke Regional Hospital in Durham, North Carolina. With 388 beds it is the second largest of Duke Health's four hospitals and offers a comprehensive range ofmedical, surgical, and diagnostic services, including orthopedics, weight-loss surgery, women's services, and heart and vascular services. Duke Nursing Highlights: Duke University Health System is designated as a Magnet organizationNurses 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! Relocation Assistance based on eligibility 40 hour and Every Other Weekend 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. Supports 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. Work Performed 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
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