Oncology Prior Authorization Case Manager, Non-RN - Remote

University of Miami•Miami, FL

3d•Remote

About The Position

The Utilization Case Manager (Remote) completes ongoing clinical utilization reviews and identifies the need for continued authorization. The role coordinates with the Nurse Case Manager and healthcare team to support optimal patient outcomes while avoiding treatment delays and authorization denials. The case manager manages a designated patient caseload and ensures that necessary criteria for continued authorization remain in place. They communicate progress and determinations to the clinical team and, when appropriate, the patient.

Requirements

Bachelor’s degree in a relevant field.
At least 2 years of relevant experience.

Responsibilities

Perform timely ongoing reviews for services requiring authorization for continuation of care.
Follow the authorization process using established payer criteria or clinical guidelines.
Review coverage benefits and limitations accurately to determine whether requested services remain appropriate.
Facilitate interdepartmental communication about continued authorization status before the patient’s appointment.
Communicate authorization status and determinations to the clinical team and, on occasion, the patient.
Identify potential treatment delays by reviewing treatment plans and proactively communicate potential barriers to the healthcare team and/or patient.
Maintain knowledge of payer reimbursement policies and clinical guidelines.
Follow University and department policies and procedures and safeguard University assets.