Job Description

Utilization Review Case Manager

The University of Miami Health System Department of UMHC SCCC Business Operations has an exciting opportunity for a full time Utilization Review Case Manager to work to work remote. 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.

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.

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