Case Manager RN - Utilization Review

University of Miami•Miami, FL

About The Position

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. The nurse serves as the subject matter expert to her team, providing support and education. Work Location : UHealth Tower

Requirements

Graduate from an accredited school of nursing, Bachelor’s degree (BSN).
Valid State of Florida RN license required
Basic Life Support Certification (BLS) from the American Heart Association required.
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.

Responsibilities

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.