Utilization Case Manager RN (H)

Utilization Case Manager RN

The purpose of the Utilization Case Manager RN is to conduct initial chart reviews for medical necessity and identify the need for authorization. The Utilization Case Manager RN 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.

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

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 Nursing
• Certification and Licensing: Registered Nurse License; Basic Life Support Certification (BLS)
• 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.