Oncology Prior Authorization Case Manager, Non-RN - Remote

University of Miami; Miami, Northern (FL, KY); Hybrid; USD 65,000 - 90,000; Full time

Job summary

The University of Miami Health System is seeking a full-time Utilization Review Case Manager to work remotely. You will perform initial, concurrent and retrospective chart reviews for clinical utilization and authorization, coordinating with the healthcare team to optimize patient outcomes while avoiding delays and denials.

Minimum requirements include a Bachelor’s degree and at least 2 years of relevant experience; oncology experience is preferred.

Qualifications

• Bachelor’s degree in relevant field; or equivalent.
• Minimum of 2 years of relevant experience.

Responsibilities

• Adheres to and performs 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 and coordinates with the team to resolve.
• Ensures effective communication regarding authorization status and determination to the clinical team and the patient when appropriate.

Education

Bachelor’s degree in relevant field; or equivalent

Job description

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 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 experienceOncology - Preferred ***Any relevant education, certifications and/or work experience may be considered***