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Utilization Review Case Manager RN - Full Time

The University of Miami is currently seeking a Prior Authorization Nurse Case Manager. The incumbent purose is to conduct initial chart reviews for medical necessity and identify the need for authorization. The nurse coordinates with the healthcare team for optimal and efficient patient outcomes, while avoiding potential 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 as it pertains to treatment or treatment barriers. Finally, the nurse serves as the subject matter expert to her team, providing support and education.

Adhere and perform timely prospective reviews for services requiring prior authorization

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 in recommended compendia and or guidelines

Serves as a resource to provide education regarding payer policies and facilitates coordination of alternative treatment options

Ensures and maintains effective communication regarding prior authorization status and determination to the clinical team and on occasion the patient.

Facilitates interdepartmental communication regarding authorization status in advance of the patient’s appointment

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.

Ensures appointment notes are in accordance with the authorization on record and the treatment plan ordered

Escalates to the appropriate department should there be a change in or lack of coverage

Facilitates communication of denials and or Peer to Peer requests between payers and the healthcare team

Identifies opportunities for expedited requests and prioritizes caseload accordingly

Serves as the subject matter expert to their assigned team for education and coordination support

Participates in performance improvement initiatives and other alike unit activities such as the denials task force and unit-based practice council (UBPC)

Adheres to University and unit-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.

CORE QUALIFICATIONS                                                                                                         

Education:

Bachelors’ degree in Nursing from an accredited college or University

Certification and Licensing:

Valid State of Florida Nursing License

Experience:  

Minimum 2 years of relevant experience

Knowledge, Skills and Attitudes:

Ability to exercise sound judgment in making critical decisions.

Skill in completing assignments accurately and with attention to detail.

Ability to analyze, organize and prioritize work under pressure while meeting deadlines.

Ability to work independently and/or in a collaborative environment.

Ability to communicate effectively in both oral and written form.

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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