Case Manager RN - Utilization Review

Work Location:

UHealth Tower Core Job Functions

• 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.
• Adheres to University and department level policies and procedures and safeguards University assets.

Education:

Graduate from an accredited school of nursing, Bachelor’s degree (BSN).

Certification and Licensing:

Valid State of Florida RN license required

Basic Life Support Certification (BLS) from the American Heart Association required.

Experience:

Minimum 2 years of relevant experience required. Minimum of one 1 year in Hospital Case Management/nursing.

Working knowledge of patient assessment, and medical terminology.

• Learning Agility:
  Ability to learn new procedures, technologies, and protocols, and adapt to changing priorities and work demands.
• Teamwork:
  Ability to work collaboratively with others and contribute to a team environment.
• Technical Proficiency:
  Skilled in using office software, technology, and relevant computer applications.
• Communication:
  Strong and clear written and verbal communication skills for interacting with colleagues and stakeholders.

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