Oncology Prior Authorization Case Manager RN - Full Time

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 using the Career worklet, please review this tip sheet.

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 He