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The University of Miami is currently seeking Utilization Review Case Manager to work at Sylvester Support Service Building in Miami. The incumbent conducts initial, concurrent and retrospective chart reviews for clinical utilization and authorization. The Utilization Review Case Manager coordinates with the healthcare team for optimal and efficient patient outcomes, while avoiding treatment delays and authorization denials. They are accountable for a designated patient caseload and provide intervention and coordination to decrease avoidable delays, at all times they provide communication of progress and or determination to the clinical team and or the patient. He/she monitors care and acts as a liaison between patient/family, healthcare personnel, and insurers. Evaluates the needs of the patient, the resources available, and recommends and facilitates for the best outcome to meet ongoing patient needs that encourages compliance with medical advice.
CORE FUNCTIONS:
Adhere and perform timely prospective review for services requiring prior authorization as well as timely concurrent review for continuation of care services
Follows the authorization process using established criteria as set forth by the payer or clinical guidelines
Accurate review of coverage benefits and payer policy limitations to determine appropriateness of requested services
Refers to the treatment plan for clinical reviews in accordance with established criteria and guidelines
Facilitates communication of denials and or Peer to Peer requests between payers and the healthcare team
Identifies potential delays in treatment or inappropriate utilization by reviewing the treatment plan, serves as a resource to provide education regarding payer policies and assists with coordination of alternative treatment options
Ensures and Maintains effective communication regarding authorization status and determination to the clinical team and on occasion the patient.
Proactive communication with leadership regarding barriers and or potential delays in care Identifies opportunities for expedited requests and prioritizes caseload accordingly
Maintains knowledge regarding payer reimbursement policies and clinical guidelines.
This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.
CORE QUALIFICATIONS:
Education:
Bachelor's degree in relevant field; or equivalent
Experience:
Minimum of 2 years of relevant experience
Oncology - Preferred
The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.
UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.
Patient safety is a top priority. As a result, during the Influenza ("the flu") season (September through April), the University Of Miami Miller School Of Medicine requires all employees who provide ongoing services to patients, work in a location (all Hospitals and clinics) where patient care is provided, or work in patient care or clinical care areas, to have an annual influenza vaccination. Failure to meet this requirement will result in rescinding or termination of employment.
The University of Miami is an Equal Opportunity Employer - Females/Minorities/Protected Veterans/Individuals with Disabilities are encouraged to apply. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Click here for additional information.
