Utilization Manager Behavioral Health

We need to output HTML fragment with sections: headings

for sections present: About the role? Actually the posting includes "About Duke Regional Hospital", "Duke Nursing Highlights", then many bullet-like sentences describing responsibilities. Also there is "Knowledge, Skills And Abilities", "Level Characteristics", "Minimum Qualifications", "Degrees, Licensures, Certifications". Also maybe "Quality of Life: Living in the Triangle!" and "Relocation Assistance". Also "40 hour and Every Other Weekend". Also "Assesses for accuracy..." etc. Need to parse. We must not repeat job title (not given). No Job ID. Remove boilerplate: EEO, equal opportunity, etc. Also remove "Duke is an Equal Opportunity Employer..." and following paragraphs about community, etc. Also remove "Essential Physical Job Functions ..." and maybe "Additional information...". Also remove navigation/cookie etc not present. We need to preserve substantive info. We need sections only when posting has real specific content. Use

for section headings: e.g., About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. But we can also use other headings? The instruction: use

for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). It suggests we should use those standard headings if applicable. But we can also use other headings? It says use

for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). Likely we should map content to those headings where appropriate. If a section doesn't match exactly, we could still use

with appropriate heading text derived from posting (like "About Duke Regional Hospital", "Duke Nursing Highlights", "Knowledge, Skills And Abilities", "Minimum Qualifications", "Degrees, Licensures, Certifications", "Quality of Life", "Relocation Assistance", "Schedule"). But the instruction: "Use

for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." It doesn't forbid other headings, but suggests those as examples. Probably we should use those exact headings when content matches. For content like "About Duke Regional Hospital" we could treat as "About the role"? Not exactly. Might be better to use "About Duke Regional Hospital" as heading. The instruction says use

for section headings (e.g. About the role, Responsibilities...). It doesn't say we must only use those exact phrases; it's just examples. So we can use any heading but wrapped in

. We'll produce sections for each meaningful block. We need to use

• for any list of duties/requirements/benefits, and

  for prose. We need to preserve ALL substantive information; do not invent or summarize away detail. We need to remove boilerplate: EEO, equal opportunity, etc. Also remove "Duke is an Equal Opportunity Employer..." and following paragraphs about community, etc. Also remove "Essential Physical Job Functions Certain jobs..." and maybe the following sentence about accommodation. Also remove "Duke aspires to create a community..." etc. Also remove "Quality of Life: Living in the Triangle!"? That's substantive about location; keep. Also "Relocation Assistance (based on eligibility)" keep. Also "40 hour and Every Other Weekend" maybe schedule. Also "Assesses for accuracy..." starts duties list. We need to parse duties: many sentences starting with "Assesses for accuracy..." etc. Those are responsibilities. We'll put them in a

  • under a Responsibilities section. Also there is "Work Performed" then a list of duties (starting with "Validates authorization...") also responsibilities. Also there is "Utilization Manager Medical Chart Auditor" then duties. Also "ED UM/CM Proactive CM screening..." duties. Thus we can combine all duty sentences into one Responsibilities list. Knowledge, Skills And Abilities: list items: Basic computer proficiency required; Ability to become proficient in 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. We'll put those as
    • under Skills section maybe. Level Characteristics: "N/A" - we should not create a section with filler. So skip. Minimum Qualifications: Education BSN required; Experience Minimum of three years recent acute clinical practice or related health care experience. We'll put under Requirements or Qualifications. 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. We'll put under Qualifications. Benefits: Relocation Assistance (based on eligibility). Also maybe "Quality of Life: Living in the Triangle!" is not a benefit but location. Could be under Benefits? Might be better as a separate section "Location" but not in list. Could treat as a paragraph under Benefits? The instruction: include a section ONLY when posting has real, specific content for it. So we can have Benefits section with Relocation Assistance. Also maybe "40 hour and Every Other Weekend" is schedule. Pay: not mentioned, so omit. Schedule: "40 hour and Every Other Weekend" maybe indicates full-time 40 hours per week, every other weekend. We'll put under Schedule. Also there is "Assesses for accuracy..." etc. That's duties. Now we need to output HTML fragment only. Structure:

      About Duke Regional Hospital

      ... description ...

      Duke Nursing Highlights

      ... bullet points? Actually it's a list of highlights: "Duke University Health System is designated as a Magnet 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". We'll make

      • for each. Then Responsibilities section: combine all duty sentences. We need to ensure we don't miss any duty sentences. Let's extract duties from text: From after "Duke Nursing Highlights" paragraph: "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 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." We need to split into sensible sentences. There's some missing punctuation. We'll just treat each sentence as a duty. We'll create a
        with each duty as
        • . Need to ensure we don't lose any. Let's list duties: 1. 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. 2. Supports the medical chart audit process by ensuring accurate, timely, and informative clinical review documentation that supports the medical necessity/level of care. 3. Supports denials management by documenting activities related to denials adjudication according to departmental guidelines and actively works to overturn threatened denial activities. 4. Complies with current rules and regulatory requirements pertaining to utilization management. 5. Initiates actions to obtain appropriate determinations. 6. Collaborates with members of the healthcare team to address, understand, and mitigate excess/avoidable days. 7. Serves as primary source of consultation for issues related to patient class (status) determination. 8. Validates authorization for all bedded patients and commercial initiatives. 9. Payer authorization within the contractual timeframe at time of presentation, every third day or as needed (e.g. ED, Direct Admit, Transfers). 10. Manage concurrent cases to resolution care that may impact payer approval to authorize care as medically necessary. 11. Conducts initial review and continued stay reviews as designated in UM plan. 12. Reviews records for medical necessity and collaborates with physician(s) and members of the care team to validate information. 13. Establishes and communicates estimated LOS and expected discharge date using GMLOS. 14. 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. 15. Facilitates mitigation of denials and peer to peer conversations. 1