Clinical Utilization Management Coordinator - RN/LPN

American Oncology Network•Macon, GA

4d•$30 - $44•Onsite

About The Position

The Clinical Utilization Management Coordinator ensures health care services are administered with quality, drug cost efficiency, and compliance with payer policy. The role continuously reviews and audits patient treatment files to help ensure treatments and procedures have payer pre-authorization, and communicates payer positions regarding medical necessity. The coordinator conducts concurrent clinical reviews, checks precertification and authorization requests, monitors treatment plans and changes that could affect authorization, and works with payers and providers to resolve coverage and authorization issues. The role keeps clinical teams informed, supports continuity of patient care, and maintains accurate documentation of utilization management activities and payer communications. The position requires managing multiple priorities in a fast-paced environment with minimal supervision.

Requirements

Graduate of an accredited nursing program.
Current state licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN).
Two years of LPN or RN experience; physicians practice experience is specified, with oncology preferred.
Two years of experience in utilization management and obtaining insurance authorizations in a medical setting.
Relevant clerical or case management work in a medical office setting.
Excellent interpersonal and communication skills.
Detail-oriented and self-starting.
Skills in communication, organization, collaboration, documentation, analysis, and advocacy.

Nice To Haves

Oncology experience.
Utilization Management or Case Management certification.

Responsibilities

Conduct concurrent reviews of patient clinical information to ensure active pre-authorization for scheduled treatments and procedures.
Review precertification and authorization requests for medical necessity and verify required approvals before treatment delivery.
Monitor new treatment plans, treatment changes, and other clinical activities that may affect existing authorizations or require additional payer approval.
Apply clinical knowledge, critical thinking, and independent judgment to authorization requirements and payer-related issues.
Communicate with payer plans regarding authorization requirements, coverage determinations, and treatment-related approvals.
Identify and communicate payer requirements that may affect treatment delivery, including formulary restrictions, pharmacy substitutions, and coverage limitations.
Partner with providers to address payer exceptions and facilitate treatment modifications required by a patient’s health plan.
Provide timely updates to physicians, clinical teams, and other healthcare providers regarding authorization status, outstanding requirements, and payer determinations.
Coordinate with clinical and non-clinical staff supporting treatments that require pre-authorization.
Escalate authorization barriers or payer-related concerns that may delay or affect treatment.
Advocate for timely, high-quality patient care while keeping treatment plans aligned with payer requirements and authorization guidelines.
Proactively identify authorization issues that could affect treatment scheduling or delivery to support continuity of care.
Maintain accurate, complete, and timely documentation of pre-authorization, precertification, payer communication, and related utilization management activities.
Maintain authorization-related records according to organizational procedures and applicable payer requirements.
Manage multiple priorities in a fast-paced environment with minimal supervision and maintain organization, accuracy, and follow-through.
Demonstrate effective interpersonal and communication skills with providers, clinical staff, payers, and other stakeholders.
Perform the essential duties of the role satisfactorily and support ongoing business operations as needed.