Oncology Prior Authorization Case Manager, Non-RN

University of Miami•Miami, FL

1d•Remote

About The Position

The University of Miami Health System Department of UMHC SCCC Business Operations has an exciting opportunity for a full time Utilization Review Case Manager to work to work remote. The incumbent conducts initial, concurrent and retrospective chart reviews for clinical utilization and authorization. The Utilization Review Case Manager coordinates with the healthcare team for optimal and efficient patient outcomes, while avoiding 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. He/she monitors care and acts as a liaison between patient/family, healthcare personnel, and insurers. Evaluates the needs of the patient, the resources available, and recommends and facilitates for the best outcome to meet ongoing patient needs that encourages compliance with medical advice.

Requirements

Bachelor’s degree in relevant field; or equivalent
Minimum of 2 years of relevant experience

Nice To Haves

Oncology - Preferred
Any relevant education, certifications and/or work experience may be considered

Responsibilities

Adhere and perform timely prospective review for services requiring prior authorization as well as timely concurrent review for continuation of care services
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 and guidelines
Facilitates communication of denials and or Peer to Peer requests between payers and the healthcare team
Identifies potential delays in treatment or inappropriate utilization by reviewing the treatment plan, serves as a resource to provide education regarding payer policies and assists with coordination of alternative treatment options
Ensures and Maintains effective communication regarding authorization status and determination to the clinical team and on occasion the patient.
Proactive communication with leadership regarding barriers and or potential delays in care
Identifies opportunities for expedited requests and prioritizes caseload accordingly
Maintains knowledge regarding payer reimbursement policies and clinical guidelines.