University of Miami
Oncology Prior Authorization Case Manager, Non-RN - Remote
University of Miami, Miami, Florida, us, 33222
Current Employees:
If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position, please review this tip sheet. 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 remotely. 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. The candidate monitors care and acts as a liaison between patient/family, healthcare personnel, and insurers, evaluates needs, recommends and facilitates the best outcomes, and encourages compliance with medical advice. Core Functions
Adhere and perform timely prospective review for services requiring prior authorization and timely concurrent review for continuation of care services. Follow the authorization process using established criteria as set forth by the payer or clinical guidelines. Accurately review coverage benefits and payer policy limitations to determine appropriateness of requested services. Refer to the treatment plan for clinical reviews in accordance with established criteria and guidelines. Facilitate communication of denials and/or Peer to Peer requests between payers and the healthcare team. Identify potential delays in treatment or inappropriate utilization by reviewing the treatment plan, serve as a resource to provide education regarding payer policies, and assist with coordination of alternative treatment options. Ensure and maintain effective communication regarding authorization status and determination to the clinical team and on occasion the patient. Proactively communicate with leadership regarding barriers and/or potential delays in care, identify opportunities for expedited requests, and prioritize caseload accordingly. Maintain 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 a relevant field; or equivalent. Experience:
Minimum of 2 years of relevant experience. Oncology is preferred. Any relevant education, certifications, and/or work experience may be considered. 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 groundbreaking 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. 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. Job Status:
Full time Employee Type:
Staff Pay Grade:
H8 Seniorities and Employment Type
Entry level Full‑time Job Function
Health Care Provider Higher Education
#J-18808-Ljbffr
If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position, please review this tip sheet. 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 remotely. 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. The candidate monitors care and acts as a liaison between patient/family, healthcare personnel, and insurers, evaluates needs, recommends and facilitates the best outcomes, and encourages compliance with medical advice. Core Functions
Adhere and perform timely prospective review for services requiring prior authorization and timely concurrent review for continuation of care services. Follow the authorization process using established criteria as set forth by the payer or clinical guidelines. Accurately review coverage benefits and payer policy limitations to determine appropriateness of requested services. Refer to the treatment plan for clinical reviews in accordance with established criteria and guidelines. Facilitate communication of denials and/or Peer to Peer requests between payers and the healthcare team. Identify potential delays in treatment or inappropriate utilization by reviewing the treatment plan, serve as a resource to provide education regarding payer policies, and assist with coordination of alternative treatment options. Ensure and maintain effective communication regarding authorization status and determination to the clinical team and on occasion the patient. Proactively communicate with leadership regarding barriers and/or potential delays in care, identify opportunities for expedited requests, and prioritize caseload accordingly. Maintain 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 a relevant field; or equivalent. Experience:
Minimum of 2 years of relevant experience. Oncology is preferred. Any relevant education, certifications, and/or work experience may be considered. 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 groundbreaking 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. 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. Job Status:
Full time Employee Type:
Staff Pay Grade:
H8 Seniorities and Employment Type
Entry level Full‑time Job Function
Health Care Provider Higher Education
#J-18808-Ljbffr