Utilization Management, Care Coordination
Wake Forest Baptist Health is a pre-eminent academic health system based in Winston-Salem, North Carolina. Wake Forest Baptist’s two main components are an integrated clinical system – anchored by Wake Forest Baptist Medical Center, an 885-bed tertiary-care hospital in Winston-Salem – that includes Brenner Children’s Hospital, five community hospitals, more than 350 primary and specialty care locations and more than 2,500 physicians; and Wake Forest School of Medicine, a recognized leader in experiential medical education and groundbreaking research that includes Wake Forest Innovations, a commercialization enterprise focused on advancing health care through new medical technologies and biomedical discovery.
Job Summary: Collaborates with social workers, case managers, physicians, peers, and third-party payers to assist with clinical information. Responsible for timely provision/flow of specific clinical information to third-party payers to ensure certification/approval of inpatient and post discharge days. Identifies and manages staffing issues. Maintains and shares knowledge related to regulations and compliance.
Education / Experience:
- Graduate from an accredited school of nursing.
- BSN required.
- Five years clinical experience required.
- Previous experience in hospital utilization review required.
- Academic medical center experience preferred.
Licensure, Certification and / or Registration:
- Current licensure to practice as a Registered Nurse in the State of North Carolina.
- Certification in case management highly recommended within 2 years.
1. Supervises team of RN case managers who handle utilization review activities for the system of network hospitals.
2. Assures that medical necessity reviews are completed on a regular basis in accordance with all state and federal regulations and the Utilization Management Plan. Demonstrates proficiency in applying nationally accepted evidence based criteria to assure appropriate hospital level of service. Serves as a resource to RN case managers in determination of medical necessity and level of care.
3. Maintains current knowledge of state, federal and commercial payer requirements and guidelines. Provides education to team members regarding these requirements/guidelines. Audits team members? reviews on an ongoing basis to assure compliance with federal regulations, guidelines and mandates (including but not limited to Condition Code 44, 2 Midnight Benchmark, Medicare Appeals).
4. Communicates with physician advisor, departmental leadership and other medical center departments regarding barriers to patient placement and/or patient progression of care. Proactively communicates issues/concerns that impede the patient treatment process.
5. Collaborates with payer, physician advisor and multi-disciplinary team to reconcile authorizations and payer-issued denials.
6.. Completes audits of staff member?s work to assess performance and adherence to productivity standards. Assures staff documentation of utilization management activities, including retroactive reviews, is timely and complete.
7. Compiles specific reports upon request to document and track utilization trends and outcomes.
8. Demonstrates knowledge of age/developmentally-appropriate patient care in accordance with Age-Specific Care Guidelines for the specific age groups served by the medical center.
Skills and Qualifications:
- Demonstrates excellent communication skills.
- Proficient with Microsoft Office.
- Ability to multi-task and organize daily flow of work.
- Attention to detail.
- Ability to anticipate payer specific stipulations.
- Ability to delegate appropriately
- Teamwork with departmental colleagues and other medical center employees.
Amount of time spent performing the following activities:
0% 35% 65%
to to to
35% 65% 100% N/A Activity
X Reaching with arms
X Finger and hand dexterity
Lifting, carrying, pushing and or pulling:
X 20 lbs. maximum
X 50 lbs. maximum
X 100 lbs. maximum
- Works in a continually changing environment.
- Clean, well lit, comfortable environment (office space)
- Moderate noise environment
- High stress level at times
- May be exposed to infectious and contagious diseases.
- Subject to many interruptions.
- Subject to irregular hours.
To apply for this position, please click on the "Apply Now" button on this page. You must complete the application process and then submit your application by clicking on the "Submit" button located at the bottom of the page titled "Submit Online Application". You will receive the following message once you hit the submit button: "You have successfully submitted your job application".
Computers are available for applying within the lobby of the Human Resources Department located at 1920 West First Street, (on the corner of Miller and First Street) Winston-Salem, North Carolina 27104. You may also call our office for assistance at (336) 716-6464. Office hours are Monday-Friday, 8:00am-5:00pm.
If you are an individual with a disability and need reasonable accommodation to participate in the application process, please contact our Supervisor of Office Services by phone (336) 716-3367 or email at firstname.lastname@example.org.
It is the policy of Wake Forest Baptist Medical Center to administer all educational and employment activities without discrimination because of race, sex, age, religion, national origin, disability, sexual orientation, gender identity or veteran status (except where sex is a bona fide occupational qualification or a statutory requirement) in accordance with all local, state, national laws, executive orders, regulations, and guidelines.