Utilization Manager

Description

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Summary:

The Utilization Manager (UM) reviews admissions, continued stays, and discharges for medical necessity and the appropriate class and level of care (LOC). The UM works with physicians, nursing, care managers, social workers, payers, and LME/MCOs so that patient needs are met and care is coordinated. All reviews follow federal and state regulations and UNC Health Pardee's Utilization Review Plan.

Assignments are made by Care Management leadership based on licensure and validated competency. RN-licensed UMs may be assigned to any patient population. LCSW- and LCMHC-licensed UMs are assigned to patients whose primary reason for hospitalization or continued stay is a behavioral health condition. The UM conducts initial screening only. Any finding that an admission or continued stay is not medically necessary is referred to the Physician Advisor, and only a physician makes that determination.

Responsibilities:

All assignments

• Applies the Approved Criteria set for the assigned population to admission, continued stay, and discharge reviews within the timeframes in the Utilization Review Plan.
• Enters all review data into the designated system completely and on time.
• Ensures pre-certification, concurrent authorization, and re-certification with commercial payers, Medicare Advantage plans, NC Medicaid Standard Plans, and LME/MCO Tailored Plans.
• Presents clinical information to payer reviewers and coordinates peer-to-peer reviews between the attending provider or Physician Advisor and the payer as applicable.
• Partners with physicians, advanced practice providers, and nursing so that documentation reflects the patient's acuity, the services provided, and the need for the current level of care.
• Communicates denials and approvals to appropriate staff, supports appeals with timely clinical documentation, and documents and delivers required notices to patients and representatives.
• Communicates daily with the care manager and treatment team to manage LOC transitions. Uses high-risk screening to make care management and social work referrals.
• Identifies high-risk and complex cases for escalation to the weekly complex case review, and follows up on all action items until resolved.
• Participates in inter-rater reliability testing and audits. Tracks avoidable days, denial reasons, and authorization trends to support department QAPI goals.

Medical/surgical assignments (RN-licensed UMs)

• Conducts admission and class-change reviews, including inpatient vs. observation status, and identifies and obtains observation services as appropriate.
• Reviews pre-scheduled surgical admissions for the correct status order on inpatient-only procedures.
• Identifies documentation that affects coding accuracy, severity of illness, and appropriate reimbursement, and guides the medical staff accordingly.
• Refers cases that do not meet criteria to the Physician Advisor according to the Utilization Review Plan. Does not make final adverse determinations.

Behavioral health assignments (RN-, LCSW-, or LCMHC-licensed UMs)

• Applies behavioral health criteria (e.g., MCG, LOCUS/CALOCUS, ASAM where applicable) across the acute hospital setting. *
• Reviews ED patients awaiting psychiatric placement, including those under involuntary commitment (IVC), and tracks status through the boarding period.
• Identifies behavioral health discharge barriers, such as placement availability, guardianship, custody, or community service gaps, and escalates them for interdisciplinary problem-solving.