Clinical Utilization Management Coordinator

American Oncology Network•Macon, GA

8d•$30 - $44•Onsite

About The Position

The Clinical Utilization Management Coordinator role is to ensure that health care services are administered with quality, drug cost efficiency, and compliant with payer policy. By continuously reviewing and auditing patient treatment files, the utilization nurse will ensure that patients won’t receive treatment/procedures without pre-authorization from payer obtained. Communicating to provider payer position specific to medical necessity.

Requirements

Graduate of an accredited nursing program with current LPN or RN licensure.
Two years LPN or RN experience; physicians practice; oncology preferred.
Two years experience in utilization management and obtaining insurance authorizations in a medical setting.
Relevant clerical or case management work in a medical office setting.
Must have excellent interpersonal and communication skills, be very detail-oriented and a self-starter.
State Licensure as a Licensed Practice Nurse (LPN) or Registered Nurse (RN)

Nice To Haves

Utilization Management or Case Management certification preferred

Responsibilities

Conduct concurrent review of patient clinical information to ensure active pre-authorization is maintained for scheduled treatments and procedures.
Review precertification and authorization requests for medical necessity and verify that required approvals are in place prior to treatment delivery.
Monitor new treatment plans, treatment changes, and other clinical activities that may impact existing authorizations or require additional payer approval.
Apply clinical knowledge, critical thinking, and independent judgment when reviewing authorization requirements and resolving payer-related issues.
Communicate with payer plans regarding authorization requirements, coverage determinations, and treatment-related approvals.
Identify and communicate payer-imposed requirements that may impact treatment delivery, including formulary restrictions, pharmacy substitutions, and other coverage limitations.
Partner with providers to address payer exceptions and facilitate necessary treatment modifications when required by the 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 impact treatment.
Advocate for timely, high-quality patient care while ensuring treatment plans remain aligned with payer requirements and authorization guidelines.
Support continuity of care by proactively identifying authorization issues that could affect treatment scheduling or delivery.
Maintain accurate, complete, and timely documentation of all pre-authorization, precertification, payer communication, and related utilization management activities.
Ensure authorization-related records are maintained in accordance with organizational procedures and applicable payer requirements.
Manage multiple priorities in a fast-paced environment with minimal supervision.
Maintain a high level of organization, accuracy, and follow-through when managing authorization activities.
Demonstrate effective interpersonal and communication skills when working with providers, clinical staff, payers, and other stakeholders.