Utilization Case Manager (Remote)

University of Miami; Miami (FL); Remote; USD 55,000 - 75,000; Full time

Job summary

University of Miami Health System seeks a Full-time, remote Utilization Case Manager to conduct ongoing reviews for clinical utilization and determine continued authorization. The role coordinates with the Nurse Case Manager and healthcare team to support timely patient care and avoid delays.

This position manages a designated caseload, communicates progress to the clinical team and patient, and adheres to payer guidelines and internal policies.

Qualifications

• Bachelor’s degree in relevant field; or equivalent.
• Minimum of 2 years of relevant experience.
• Knowledge of utilization management processes and payer guidelines.

Responsibilities

• Perform timely reviews for services requiring authorization for continuation of care.
• Follow the authorization process using established criteria from the payer or clinical guidelines.
• Review coverage benefits and limitations to determine continued appropriateness of services.
• Communicate status of authorization to clinical team and the patient as needed.
• Identify potential delays in treatment and proactively communicate with the healthcare team and patient.

Education

Bachelor’s degree in relevant field; or equivalent

Job description

UMHC-SCCC - Business Operations has an exciting opportunity for a Full time, Remote, Utilization Case Manager position. The incumbent is to complete ongoing reviews for clinical utilization and identifying the need for continued authorization. The Utilization Case Manager coordinates with the Nurse Case Manager as well as the Healthcare team for optimal patient outcomes, while avoiding potential treatment delays and authorization denials. The Utilization Case Manager is accountable for a designated patient caseload and ensures that all necessary criteria for continued authorization remains in place. At all times the case manager provides communication of progress and or determination to the clinical team and or the patient.

Core Job Functions

• Adhere and perform timely reviews for services requiring an authorization for continuation of care
• Follows the authorization process using established criteria as set forth by the payer or clinical guidelines
• Accurate review of coverage benefits and limitations to determine continued appropriateness of services requested Facilitates interdepartmental communication regarding status of continued authorization in advance of patient’s appointment.
• Maintains effective communication regarding authorization status and determination to the clinical team and on occasion the patient.
• Identifies potential delays in treatment by reviewing the treatment plan and proactively communicates with the healthcare team and or patient regarding the potential treatment barrier
• Maintains knowledge regarding payer reimbursement policies and clinical guidelines.
• Adheres to University and department level policies and procedures and safeguards University assets.

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.

Qualifications

CORE QUALIFICATIONS

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

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. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.

Job Status:

Full time

Employee Type:

Staff